Holding a Mother in Mind

This past week in my pediatric practice I saw, with their babies, three mothers who all described highly troubled relationships with their own mother. The relationships were full of grief and loss (to protect privacy, I will not give any details). Now mothers themselves, they were struggling. Their babies were clingy and irritable. They were poor sleepers, waking many times a night to nurse. They refused to take a bottle.

John Bowlby, under the influence of Charles Darwin, described the essential role of attachment relationships in survival. He 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 similarly recognized the need for a mother to have a secure base of her own in order to provide this for her child. In a 1980 lecture entitled "Caring for Children," reprinted in his book A Secure Base, he said:

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 the grandmother is not nearby or even if she is deceased, this relationship can provide the secure base she needs when she becomes a mother.

But these three mothers did not have this secure base from which to parent their young child( and they certainly didn't have help with household chores!!)

Sometimes when I sit on the floor with these mother-baby pairs, and listen to the mothers' story while the child explores the room, I feel that I am in a way in the role of good grandmother. I give a mother time and space to relax and be heard with the hope that this will fortify her in her efforts to be a secure base for her child.

One mother came in with her toddler, collapsed on the couch and proclaimed,"He's having a terrible day." Her son was very fussy and easily exploded in frustration. But as she and I spoke, he seemed to relax. He climbed off her lap and explored the different toys in the room. At a few instances we could see that he might lose it, such as when his mother told him not to draw on the table with markers, but she was able to redirect him without precipitating a tantrum. When towards the end of our 50 minute visit I commented at how well he had done, she agreed that he was much more calm than he had been the rest of the day.

I am certainly not alone with this idea. The field of infant mental health grew out of the work of Selma Fraiberg who, in her groundbreaking 1974 paper, Ghosts in the Nursery, describes what was termed 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 home, they 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. But it was different from therapy with the mother. The aim of the intervention was to help the mother to connect with her child in a meaningful way. Daniel Stern, Tessa Baradon and Alicia Lieberman, among many others, have continued and elaborated upon this tradition.

The difference between my practice, however, and that of infant mental health practitioners, is that parents come to a pediatrician expecting "advice" about what to do. The slew of parenting books and articles with such titles as "How to Get Your Child to Listen" or "Seven Essential Steps for Effective Discipline," support this way of thinking. The father of one of these babies became very frustrated when after two visits I had failed to "make the baby sleep at night."

Our culture's endorsement the use of psychoactive medication for very young children similarly promotes the idea of the "quick fix." The parents of one of these babies were so convinced that his irritable nighttime behavior was actually a seizure that I referred them to a neurologist. After an EEG determined that there was, in the neurologist's words, "nothing wrong," he recommended a tricyclic anti-depressant.

My sense is that our culture is moving away from a simplistic, "quick fix" view of mental health, which has been promoted by the combined influences of the pharmaceutical industry and health insurance industry. I hope that the wealth of knowledge about human development, and the critical role of early relationships in promotion of mental health, emanating from the discipline of infant mental health, will continue to penetrate throughout our healthcare system.

Mindful Psychopharmacology

I was pleased to read the overwhelmingly positive response to Daniel Carlat's New York Times Magazine piece Mind Over Meds in the letters to the editor, including my own.

Perhaps we are at the end of an era where, under the influence of the pharmaceutical industry and health insurance industry, clinicians prescribe psychoactive medication in 20 minute visits, with minimal attention to the experience of the person they are treating.

I am not "against" psychoactive medication, which can, in certain circumstances, offer significant benefit. Framing of the discussion as being pro or anti-medication leads to antagonism and polarization, which is not useful. Rather I would advocate for "mindful" use of medication.

David Mintz and Barri Belnap, psychiatrists at the Austen Riggs Center, in a 2006 article in the Journal of the American Academy of Psychoanalytic and Dynamic Psychiatry propose the term "psychodynamic psychopharamcology." Such an approach looks at the patients experience as a whole rather than focusing exclusively on symptoms and dose of medication. They reference a 1996 NIMH study showing that patients who had a good relationship with their doctor and took a placebo had a greater reduction in symptoms than patients who had a poor relationship with their doctor and received an active drug.

Mintz and Belnap quote Sir William Osler, the father of modern medicine, who said, "It is much more important to know what sort of patient has a disease than what sort of disease a patient has." In the conclusion, they write,

A straightforward "scientific" approach to prescription establishes a "rational" basis for treatment choice, but runs the risk of neglecting the unique impact of the patient's subjectivity, failing to attend to the patient's authority and missing the importance of relationships and of meaning to cure.

Both Carlat and Mintz's articles focus on use of medication in adults. For children the issue is equally important and significantly more complex. Family and developmental issues must be taken into account.

For example, a 10 year old boy I treated did very well initially on stimulant medication. As he entered adolescence, he began to display developmentally appropriate argumentative and occasionally oppositional behavior. His parents attributed his behavior to a "symptom" of his ADHD. All family conflict was channeled into discussion of his dose of medication. In turn he became increasingly angry, perhaps because his experience was not recognized and his legitimate feelings attributed to a "disease." The long term consequences on this boy's development of such behavior cannot be good. Dr. Mintz, in his work with seriously troubled young adults, has seen up close the ill effects of disregard for a child's developmental context, and in his words,"funnelling" of all family problems into a child's medication.

Kyle Pruett,a child psychiatrist at the Yale Child Study Center, has an eloquent discussion of this subject in Pediatric Psychopharmacology: Principles and Practice.Two Harvard psychiatrists, Peter Chubinsky and Nancy Rappaport, have an article in the 2006 Journal of Infant, Child and Adolescent Psychotherapy entitled, "Medication and the Fragile Alliance: The Complex Meaning of Psychotropic Medication to Children, Adolescents and Families"


I hope that clinicians who prescribe psychoactive medications for children, including both pediatricians and child psychiatrists, will incorporate "psychodynamic psychopharmacology" into their practice, and think about the complex meaning of medication for children and their families. Equally important is that our culture change our expectation, and accept the limitations, of the role of medication in promotion of children's mental health.

Resource for Parents

This will be a very brief blog post, simply meant to call attention to a valuable resource for parents. The Pacella Parent Child Center, which is located in New York City, offers the kind of support for parent-child relationships that I write about in my blog. The website also offers articles for parents on such common challenges as post partum depression, crying, sleep and separation issues.