Claudia Gold on The Silenced Child
On the future of mental health
Posted Feb 07, 2016
The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.
Interview with Claudia Gold
Our children are increasingly being viewed as “little patients” whose every behavior and every emotional state are designated “symptoms of a mental disorder” and who, even at the youngest of ages, are being prescribed so-called “psychiatric medication,” often with disastrous, life-long consequences. Claudia Gold speaks eloquently about what is wrong with this model and what we ought to be doing instead.
EM: Can you tell us a little bit about your new book The Silenced Child?
CG: This book grew out of many years of experience as a pediatrician when I observed the standard of care to be prescribing psychiatric medication to children without opportunity to listen to them or their families. In parallel to this experience, I was learning to appreciate behavior as a form of communication, and to recognize how healing occurs when we listen to that communication. Through my studies as a scholar with the Berkshire Psychoanalytic Institute, followed by a fellowship in infant mental health, I was exposed to a wealth of research offering evidence for an alternative model of mental health care from that offered by biological psychiatry.
My thesis is that our current system of care, in which we simply label behavior and seek to eliminate it with behavior management or increasingly medication, may interfere in a child’s development if we do not protect space and time for listening. The evidence that I offer for my thesis is the wealth of new research at the interface of developmental psychology, neuroscience and genetics showing how the brain grows in relationships, integrated with the many stories I have heard from children and families in my 25 years practicing pediatrics. Behind every “behavior problem” is a story that gives meaning to that behavior. Only when we know that story do we know how to help that child and family.
EM: One of your interests is the idea of “lifelong resilience”? What do you mean by that and do you have some top tips for “acquiring” that?
CG: D.W. Winnicott, pediatrician turned psychoanalyst, described the concept of the “good-enough” mother as central to healthy emotional development. This mother is not “perfect” but rather fails at times to meet the infant’s needs, in relation to his growing ability to manage that frustration. Child development researcher Ed Tronick offers evidence for this clinical observation. He shows that the inevitable mismatches, or disruptions in relationships, that occur in the everyday minute-to -minute interactions, when the majority are recognized and repaired, lead to the development of resilience. In early childhood, when the brain is most rapidly growing, a child acquires the ability, in both his body and his brain, to manage stress and to continue to develop in the face of the disruptions that occur throughout the lifespan. Resilience develops naturally when the growing young child survives these inevitable disruptions.
In contrast, in the face of disruptions that are not repaired, for reasons such as parental mental illness, emotional and physical neglect, or abuse, the child’s brain and body do not develop a healthy stress response. This chronic, unrepaired mismatch is what underlies much so-called mental illness. The “tip” I would offer would be as a society to listen to and protect these earliest relationships, and to identify these problems early, when the brain is most rapidly growing.
EM: You are also interested in the subject of “screening for mental disorders.” What are your thoughts on that?
CG: If screening means the ability to identify and listen to individuals with emotional suffering then I think it is important. But that is not what it means in our current health care system. Screening usually involves giving a questionnaire in the primary care setting. In that setting, due in large part to our complex and powerful health insurance industry, clinicians are being forced to see more patients in less time and do not have opportunity to listen to the patient. Referral is also difficult. A severe shortage of qualified mental health professionals is integrally tied to the fact that as a culture we condone use of psychiatric drugs in the absence of listening.
This leads to the devaluing both culturally and monetarily of professionals who offer space and time for listening. In the absence of opportunity for listening, the result of screening for “mental disorders” (see next question) is often prescribing of psychiatric medication alone. We eliminate problem behavior without opportunity to discover meaning, with opportunity to learn what the behavior is communicating. In effect we are silencing communication with this form of treatment.
This is particularly worrisome in the case of postpartum depression screening where medication places the problem squarely in the mother. This approach fails to recognize the full complexity of the transition to parenthood and lets us off the hook for addressing the severe lack of social support for mothers in the postpartum period. In fact, well-meaning efforts may result in a worsening of the very problem we are trying to address by allowing us to neglect these early relationships.
EM: What are your thoughts on the current, dominant paradigm of “diagnosing and treating mental disorders” and the use of so-called “psychiatric medication” to “treat mental disorders” in children, teens and adults?
CG: We urgently need a new paradigm of mental health care, one that is offered by the discipline of infant mental health. This paradigm is relational, developmental, multidisciplinary and reflective. The DSM paradigm conveys a false certainty that these so-called disorders are real biological entities, when in fact they are simply collections of behaviors, or “symptoms.” A classic example of the danger of this model is represented by recent research by Joan Luby at Washington University looking at brain scans of children with so-called preschool depression as diagnosed by the DSM, and demonstrating, with brain scans, changes in the brain over time. A summary of her study concludes with this statement "the next few years promise to yield information that we can use to best treat and, ultimately, prevent the occurrence of brain-based disorders." This view fails to recognize the relational and developmental context of these problems, placing the problem squarely in the child. In a system of health care that does not offer opportunity to listen to these families and understand the meaning of behavior that has been labeled as “depression,” this approach leaves the door wide open for pharmaceutical companies to aggressively market SSRI's to very young children.
EM: If you had a loved one in emotional or mental distress, what would you suggest that he or she do or try?
CG: In the last section of my book, entitled “ways of listening,” I describe opportunities that will become available once we protect the space and time. In the first, “Listening to the Body” I review the evidence for a significant role of sensory processing in the development of problems of emotional regulation, and the need to find creative ways to address these problems that are tailored to the individual. I recently learned of a former patient who is now as an early teen an accomplished fencer who gains great pleasure and positive self-esteem as well as physical health through this activity. At the age of three he was thought to have depression. His parents resisted making a diagnosis and instead sought support for themselves in understanding the meaning of his behavior. They sought ways to support him given his unique qualities that as a young child were vulnerabilities, but now are being transformed into strengths.
The second is listening for loss. Often loss, not only by death but also in disruptions in significant relationships, is at the root of emotional suffering. And last is the need for listening with courage, to tolerate uncertainty to allow an individual to grow into himself without the need to name “something wrong” with him. Quality psychotherapy, where the focus is on understanding rather than managing, together with a search for opportunities to transform vulnerabilities into strengths, is the approach I would take, and have taken, for my own family.
Dr. Gold is a pediatrician and writer with a long-standing interest in addressing children’s mental health needs in a preventive model. She currently specializes in early childhood mental health. She is on the faculty of William James College, the Berkshire Psychoanalytic Institute, and the Austen Riggs Center. She is the author of Keeping Your Child in Mind: Overcoming Defiance, Tantrums and Other Everyday Behavior Problems by Seeing the World through Your Child’s Eyes (2011) and the forthcoming The Silenced Child: From Labels, Medication and Quick-Fix Solutions to Listening, Growth and Lifelong Resilience (May 2016)
Eric Maisel, Ph.D., is the author of 40+ books, among them The Future of Mental Health, Rethinking Depression, Mastering Creative Anxiety, Life Purpose Boot Camp and The Van Gogh Blues. Write Dr. Maisel at firstname.lastname@example.org, visit him at http://www.ericmaisel.com, and learn more about the future of mental health movement at http://www.thefutureofmentalhealth.com
For more information and/or to purchase The Future of Mental Health visit here
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