Monday, 12 November 2012
So I will not add another chapter this week to my vision of the dance between genetics and environment and the origins of mental illness.
I hope I have engaged you in this dance, as it begins in the first years of life.
I hope I have brought a slightly different perspective of the context of mood states and the relational nature of our selves as we emerge from potential selves to actual selves.
My hope here is to break out of the dichotomy of genetic determinism and its opposite pole of environmental determinism. In breaking out of these two positions I hope to get away from the idea that mental illness needs to be blamed on individuals. Nuclear families (and sometimes single parents) have the burden of being the guardians of children's development on their shoulders in our modern world. Yet they cannot be expected to carry this burden alone. We must join them in taking responsibility for the environment of development as a society. Blaming parents for the ills of children is counterproductive and unfounded. Parents are usually doing their very best in difficult situations. I believe in shared responsibility, not blame. As mental health providers we can take our share of responsibility and empower others to take theirs, while facilitating access to the support that will make this possible.
The idea of genetic determinism is tempting as an ideology which absolves others of responsibility, but it is untenable. Genetic determinism also disempowers the individual and the family suggesting that genetics is destiny and that only perhaps genetic interventions or alternatively palliative psychopharmacology are options. These are false conclusions.
I hope you have a good November week.
Sunday, 4 November 2012
Our modern world can pose enormous challenges for the relationships we rely on most. In this post I want to explore the attachment relationship and what we have learned about the instinctual reactions manifest by children and adults when they perceive these reactions as threatened.
John Bowlby and his colleague James Robertson created a documentary in 1952 titled “A Two Year old goes to the Hospital”. This film depicted the series of stages a two year old underwent while hospitalized and separated from her parents. At the time it was hospital policy for children to be separated from parents while undergoing hospital treatments, with parents having as little as once a week contact with their hospitalized child. This was a practice that would change, in part due to this very documentary, as viewers of that time reacted with concern to the impact of such separations on very young children.
Stages of Detachment
In his seminal work, Bowlby explored attachment disruptions of various kinds and detailed children's emotional reactions to these disruptions. When attachments are threatened, children react at first with anxiety, a high energy state that promotes calling and clinging. When attachments are threatened further these reactions are often heighten into a stage he referred to as protest, which can include anger. Bowlby proposed that this high energy state might allow a child to overcome obstacles to reuniting with the attachment figure and communicate reproach in an effort to discourage the attachment figure from becoming unavailable in the future. If these efforts fail, the subsequent stage Bowlby described was the low energy state of despair, characterized by sadness, listlessness and resignation. One can see how this would also be an adaptive survival behavior for a child, conserving energy and avoiding danger when separated from a parent. This stage was followed by a stage Bowlby referred to as detachment. In this stage the child mobilizes energy, but attachment emotions are downplayed. Bowlby hypothesized that this was a defensive reaction, inhibiting unhelpul emotions in order to go about the necessary activities of survival. In hospital, the youngster would start to allow care from the nurses and engage in day to day activities. However when parents would return, children would ignore or avoid them. This detached reaction could go on for some time before the child would begin to demonstrate attachment emotions (including anger and clinging) towards the parent once again. Bowlby's stages may sound familiar, as they are related to the stages of grief and loss that we continue to manifest throughout adult life as we respond to threats or losses to our ongoing attachment relationships.
In our modern world we no longer separate children from their parents in hospitals. However our children do experience long periods of separation from parents. In overcrowded daycares and schools, often with both parents employed to meet the demands of modern expenses, very young children continue to experience threats to attachment. Parental isolation and depression can lead to parents being unavailable due to their own emotional states. Children frequently turn to other children for their attachment needs, a pattern that has become increasingly common as children can now contact one another easily with electronic devices. Although more common in adolescence, children can turn towards other children as their source of comfort and preferred source of positive attention. In this process they start to identify with peer values rather than adult values, much to their parents chagrin. Within these unstable relationships with peers, children can turn on one another or themselves in an effort to gain the acceptance and security that they crave. Parents can often feel helpless to reestablish these bonds once they have fractured despite their best intentions.
Chidren react, Parents react
Sunday, 28 October 2012
Finding Home Base
In this post, I want to discuss the concept of attachment, first identified by John Bowlby in the 1950s. Attachment is a relationship between an infant and its parent that evolves through the first year and a half of life. It is a process whereby an infant creates a “working model” to predict and direct the availability (that is the accessibility and responsiveness) of caregiving others in their world. In this process infants figure out in whose arms they will find comfort when it is needed and how to get it.
The attachment system is a motivational system which leads the infant to seek out its caregiver for safety, security and protection when it is distressed. When the attachment system is aroused the infant is less able to calmly explore their surroundings. The infant will vocalize and call the caregiver and, when able, will move towards the caregiver. When they have safely been reunited with the caregiver, the distress resolves, the infant is comforted and they can resume exploration. The biological utility of this behaviour is clear. In the process of evolution, having a well-tuned attachment system maintains the safety and security of infants in an uncertain world. The neurobiology of this system is now well understood. A stressful situation activates the infants sympathetic nervous system (speeding up heart rate and mobilizing energy), the motivational system (involving the dopamine system) is now directed away from exploration and towards seeking out the caregiver When this is achieved the infant is soothed and comforted (a process involving oxytocin, serotonin and endorphins). When this behaviour pattern works, it is reinforced. If it is not successful, other patterns of behaviour emerge.
The Strange Situation
Mary Ainsworth, a colleague of Bowlby, was a pioneer in studying toddlers’ attachment behaviour. She set up a series of laboratory scenarios that would mildly stress toddlers and observed how they responded. She identified three patterns of attachment. Further work by Margaret Main added a fourth pattern.
Secure or Insecure
Active or Passive
Attachment patterns are strategies of communicating with a caregiver, and the ability to use that caregiver to become calm when faced with stress. Avoidant children have learned not to call their parent, as calls have not been attended to, or they have learned to inhibit their calls, having determined it is best not to burden their caregiver unless it is very necessary. Ambivalent children have learned to turn up the volume of their protests when distressed. They demand the presence of the caregiver loudly, and have determined that this is the best strategy for getting their needs met. In the end we have extremes of active versus passive strategies. Disorganized children may flip flop between these strategies, at times seizing control, and other times becoming passive. It is important to point out here that the child’s behavior is not related to the parents love for their child. Parents who very much love their children can be unavailable for many reasons or can be stressed by a multitude of factors. Also genetic or environmental (toxins/medical/trauma) factors may interfere with a parent's capacity to soothe a child despite their best efforts and availability. Any one of these strategies may be a functional strategy in such situations for a child.
Sunday, 21 October 2012
Parents Say No
Shame and Repair
Tigger vs Eeyore
By the time this second developmental period is over, children will have developed a consistent pattern of mood states which form their emerging character. Much like the characters from the children’s story Winnie the Pooh, some will bounce along in persistent high energy states, rather impervious to direction, much like Tigger. Others will spend much of their time in highly anxious mood states, sensitive to direction, much like Piglet. Still others will reside in chronic low energy, high shame, mood states like Eeyore. And still others will lurch dramatically between mood states, more like Jeckyl and Hyde. Ideally there will be smooth and flexible mood states. With flexibility, comes the ability to take responsibility for one’s actions and tolerate responsibility, frustration and even failure while not feeling crushed by these experiences. What is critical to understand is that the relationship is at the center of this development. It is in the relationship that the ability to regulate sensation (last post) develops and it is in the relationship that the ability to regulate mood states develops. Biological factors can make the difference between children who are likely to overreact, and those that are likely to underreact, but these patterns will develop in the relationship and, with support, relationships can lead the way to new abilities which may develop at any time in the lifespan.
Sunday, 14 October 2012
Who are we?
The debate whether we begin our lives as a “tabula rasa” (blank slate) verses having our development predestined, be it from God or from genetics is an ancient one. In addition to this, I want to explore the question of how much we can know about who we are. You may have heard of Renee Descartes, a philosopher who famously said "I think therefore I am", ushering in an era of human rationality known as the Enlightenment. Descartes was referring to the amazing ability we humans have for conscious reflection. Certainly this amazing ability is a powerful tool, but modern neuroscience increasingly reveals that, in fact, it represents only a relatively small proportion of who we are.
Neural development, of course, involves all the major structures of the brain, however development appears to occur earlier for certain structures than others. Interestingly, it is the right hemisphere that appears to develop earliest. You may know that we humans have an interestingly divided neurology. We have a cerebral cortex, that highest level layer of our brain, that is divided in two, joined by a remarkably narrow strip of brain matter known as the corpus callosum. Each side of the brain is preferentially connected to the opposite side of the body, but these two hemispheres have also been shown to have very different ways of processing our lived world. A recent work by Iain McGilchrist (The Master and his Emissary) does a comprehensive job of illustrating the implications of this lateralization of human consciousness.
Nature and Nurture
Michael Meaney is a Canadian researcher who has done some fascinating work in the implications of infant mother interactions and the implications for this for gene expression. The word for environmental experiences that influence gene expression is “epigenetics”, and our understanding of this process is only just beginning. These very early interactions appear to be fundamental in the expression of certain genes that have major implications for behaviour and stress reactivity. In rats, the parental behaviour that triggers gene expression is anogenital licking. In humans it is a series of interactions that lay the groundwork for our ability to navigate the sensory and interpersonal world that we will be living in.
Even prenatal development involves more than simple genetic unfolding. We know that stress during pregnancy increases the risk for premature birth and low birth weight, which are associated with various adverse health and developmental outcomes. Some recent studies have suggested increased rates of ADHD, anxiety and mood disorders, although this is a surprisingly under-researched area. Temperament may also be affected with infants whose mothers have been highly stressed showing temperaments at the extreme ends of the spectrum. It seems that genetics does contribute significantly to temperament at birth, determining how an infant may respond to stress, with either increased or decreased reactivity to stimulation.
The first nine months or so of human development involve an incredible surge of brain development. The senses of smell and touch are most important initially, when physical contact are paramount. Vision and hearing then play an increasing role. Here our preoccupation with the human face and voice begin. In particular, the eyes. Babies seek out the face of the mother and an incredible conversation begins. A conversation held with caresses, flashing eyes and playful vocalizations. In this interaction the baby develops an increasing ability and even enthusiasm for processing information. The mother is the guardian of stimulation. It is her job to optimize the amount of stimulation, much of it which will be coming from her. A "three bears" rule of not too little, not too much rule is something the baby manages on his end by seeking, calling and looking away. The mother intuitively responds to these cues from her end. The match between the mothers natural inclination to stimulate, her stress level, and the infants partially genetically determined optimal window of stimulation seems to be key here. This is what some researchers have referred to as “goodness of fit”. This window is a sensitive one and as we know from "Still face" experiments, a period of rupture from this dance of interaction can be very distressing for the infant, who as yet cannot navigate this world of stimulation.
Orchids and Dandelions
Some genetics appear to allow children to develop well enough in a wide range of environments while other genetics lead to high sensitivity which appears to lead to very good outcomes in well matched environments but very poor outcomes in other environments. Bruce Ellis, a family researcher at University of Arizona, coined the term “orchid children” to refer to these highly sensitive children with the more fragile genetic make-up. He referred to the hardier children as “dandelion children".
Introverts and Extroverts
In the first nine months of life the basic ability to regulate stimulation is beginning to develop. Allan Schore, in his series of texts, has compiled vast amounts of interdisciplinary research tracking the neural pathways in the right hemisphere that link our sensory brain to our planning brain and relay directly to our limbic system (emotional, physical control centres) that encode these mind-body interactions which we refer to as sensory-emotional regulation. Do you shy away from busy situations or do you seek them out? Do you detest quiet setting or do you thrive in them? This dance of genetic potential with environmental feedback in these nine months has a lot to do with it. Remember however that mother alone is not responsible for what happens here. Mothers themselves (as you might remember from my last post) are not islands. Their own stress levels are dependent on those around them. The support of fathers, extended family and the broader community has everything to do with the stress level under which any mother will be operating both during pregnancy and thereafter. Our society as a whole has responsibility for how stressful an environment these early years will be.
Change is possible
Sunday, 7 October 2012
Not just another Ape
From Matriarchs to Patriarchs
The Modern World
An afterthought… I don't mean to come across as all “noble savage”. Hunter gatherer life was hard, and lifespans were short. The modern world has unleashed amazing creative potential in science, arts and medicine. I don't propose a retreat from modernity. What I propose is applying ourselves to understanding our modern ills holistically, so that we can find a way to apply this amazing creative potential to modern solutions.
Tuesday, 2 October 2012
As you may know psychiatry has gone through phases over its history. From the outset there have been two dominant schools of thought in terms of mental illness. A moral model which sees mental illness as a moral or spiritual problem and a medical model which sees mental illness as a disease of the brain. Both of these competing models still exist in various form today. (More on this in future posts.) The turn of the century saw the dawning of the psychoanalytic model which framed mental illness as "conflict" between conscious and unconscious processes, where unconscious drives overwhelmed the conscious mind leading to various symptoms of illness. As the century progressed a new paradigm took centre stage. Behaviourism arrived with the discipline of research based psychology. Behaviourism developed models of learning and behaviour that could be measured for research purposes, and dismissed motivational and emotional states that were more difficult to measure. Both of these models were fruitful in different ways but also led down sometimes unhelpful roads. Unhelpful interpretations of the psychoanalytic model such as the common understanding of Dr. Spock's advice came on the scene. This interpretation was that all we had to do was love children unconditionally and they would thrive. This unfortunately missed the fact that it is natural for us to have expectations of children and give them responsibility, which they often resist. From the behaviorists came recommendations to reward and punish and shape children's behaviour much as we would train circus animals. This misses the point that rewards and punishments only work in the context of a healthy relationship which they themselves do not help establish.
Fortunately there have been new developments in the realms of developmental science upon which we may draw. In the 1950s John Bowlby and his student Mary Ainsworth introduced Attachment Theory to our theoretical repetoire. Borrowing from ethology, these clinicians used observational methods to establish that children develop patterns of behaviour in a relational context with their parents to establish a predictable pattern of establishing security which endure over time, generalize to relationships with significant others and romantic partners, and are often passed on from parent to child. New developments in behavioral neuroscience such as the establishment of the existence of mirror neurons and research on the process of parent child attunement have helped us gain an improved understanding of the developmental pathways for empathy and of theory of mind. These developments allow us to understand that learning occurs best in an attuned and secure relationship and at best involves more than simple conditioning.
On the Adolescent Psychiatric Unit we have followed a model of "Collaborative Problem Solving" (with start up consultation from Ross Greene). What we have moved away from is the model of Behaviour Modification which still dominates on many, perhaps most, hospital wards. In the Behaviour Modification model rewards are given for desirable behaviour and consequences meted out for undesirable behaviour. The problem with the behaviour modification model is that those who can cope with it are rewarded while those who can't are punished. What you get in the end is extremes of behaviour. Studies have shown that these kinds of interventions increase the rates of seclusion and restraint. Collaboration involves having and discussing expectations while taking the time to listen to the concerns and expectations of the young person. It involves understanding that young people may not always be able to meet our expectations, but that there are many different reasons why they may not. Using this model we can learn what some of the barriers to meeting the expectations of others might be in this particular child, increasing our understanding, while improving communication skills and trust. In a relationship where kids feel safe and understood they usually come to accept the expectations of others. So far this model has worked well for us, although it can be challenging and requires more thoughtfulness and effort than a simple behavioral model would require. Overall the results have been rewarding and our restraint and seclusion rates have been near non-existant.
I am a Psychiatrist working on a specialized hospital unit for young people struggling with mental health issues in Kelowna, British Columbia, Canada. I also work on call at this hospital and am consulted to support young people in crisis in the Emergency Department and on the Paediatric Ward.
As you can imagine this kind of work forces one to confront some challenging ethical questions as well as some important theoretical questions, such as:
What exactly is mental illness?
What aspects of treatment should young people decide for themselves, how does this change with development?
What aspects of treatment should people with mental illness decide for themselves?
What is the role of family in these decisions?
How do we address the behaviours of young people, or mentally ill people in the hospital?
How do families address the behaviours of young people, including those with mental illness at home and how is this the same or different?
What is the role of medication in treating young people?
What is the role of various other treatments in the hospital and after hospital in treating young people?
I see this blog as being a forum for discussion on these topics. My team here on the Adolescent Psychitric Unit have wrestled and continue to wrestle with these questions and I will share some of our philosphical postitions on these matters in this blog as well as the role of various advances in the realm of developmental science and neuroscience that might inform these questions.