by Yvon Gauthier, M.D., CACAP Life Member
Early this last summer I happened to read in The New York Review of Books Marcia Angell's review of three recent publications, which she entitled : "The Epidemic of Mental Illness - Why?" (Angell, 2011). What she summarized emphasized the dramatic situation of psychiatric practice, and I spent a good part of my summer reading those three books (Carlat, 2010; Kirsch, 2010; Whitaker, 2010). From different perspectives the three authors deeply question the evolution of the psychiatric field towards the enlargement of criteria for the diagnosis of mental illness, the strong influence of the pharmaceutical industry on prescription of drugs even when research is far from being clearly positive, and a significant tendency of psychiatrists to follow this movement. Even though such phenomena particularly concerned adult psychiatry, in all three books chapters describe a similar situation in child and adolescent psychiatry.
As I was going through these very interesting books, I could not help feeling confirmed in what had been until then "personal impressions", leading over the years to much disquietness and worry. It was hard to believe that new data were leading to an important questioning of what seemed an unstoppable movement. Let me explain my reaction.
In the late '90s, early 2000s I became more and more aware that something important was happening in our field. I could no longer ignore the fact that more and more often we were seeing hyperactive children who experience early in their lives enormous difficulty in concentrating and sitting long enough to complete the steps that lead to successfully completing rather simple tasks, and that the treatment of such disorders had become almost exclusively pharmacological. I was regularly observing that medications such as amphetamines, anxiolytics, antidepressants and even antipsychotics were increasingly used to relieve anxiety, sadness and behavioral problems. I also observed that child psychiatrists now argued about bipolar disorder, a disease of adults that seemed to be diagnosed earlier and earlier in the life of the child, based on criteria that remained unclear. Most conferences and symposia in our community seemed almost exclusively devoted to the psychopharmacology of various disorders encountered in children and, similarly, Canadian and American scientific journals seemed to publish mainly the work of researchers in this domain. Under the influence of the DSM-IV, child psychiatrists tended to focus primarily on symptoms, often forgetting that establishing a relationship with the child and his family was an essential part of any therapeutic effort. I thus perceived a fairly widespread trend towards the abandonment of all that concerns the inner conflicts of the child and family dynamics.
In our Hospital department, in their assigned presentations residents were regularly choosing to talk about organic or neurological syndromes where psychopharmacology was expected to be the major therapeutic instrument. One seminar stands out as specially symbolic of this movement toward unilinearity. This 10-year-old girl - as evidenced in video sequences - was suffering from a severe Tourette syndrome. During her whole presentation a senior resident, well supported by a known neurologist specialized in this illness, made a precise and very scientific description of all the medications that were tried in succession during several months in an attempt to alleviate this symptomatology, without any real sucess. It is only after these unsuccessful measures that the team finally asked a psychoeducator to work with this girl. She was able to make her aware of the bodily signs that were announcing the crisis of tics, and family sessions were also held where her older adolescent sisters were able to talk about their demeaning attitudes toward her sibling, much around her symptoms. It became clear that those measures were critical in leading to an important decrease of the symptomatology and a gradual return to school attendance.
Why was I so worried? This movement evidently struck at the heart of my professional identity. Trained as an adult and child psychiatrist and analyst in the late '50s in Philadelphia, my whole career as clinician-teacher-researcher was spent in a large paediatric university hospital in Montreal, seeing and psychodynamically treating children of all ages with varied sympyomatologies, often coming from paediatric wards, and teaching residents and medical students along psychodynamic understanding. Had we wasted our time and energy all those years? It is true that we often took as self-evident the theories we were teaching and working with, but had we erred to the extent that the whole system should be dumped more or less subtly?
I found myself often reflecting on my own journey from classical analysis to a practice that was much involved in psychosomatics and gradually centered on infants and young children, where attachment theory had become a most useful instrument. These reflections finally led to writing a book : "L'Avenir de la psychiatrie de l'enfant. Le parcours d'un psychiatre d'enfant" (Editions Érès, Toulouse, 20092).
In this process which lasted several years I became deeply aware that as much as we were observing a strong movement towards biology - all this new knowledge on brain functioning, on genes and neurotransmitters - child psychiatry was also in the midst of a strong movement centered on the observation of the child's early infant-mother interactions, on the place that Bowlby's attachment theory was taking in research. I was particularly impressed by the several high-quality longitudinal researches leading to clear correlations between early experience and later outcome (Grossmann et al, 2005). We could also observe that within this movement several teams of clinicians-researchers, most often influenced by attachment concepts, had attempted to apply early intervention techniques with disadvantaged populations with the objective of developing a secure attachment and thus preventing psychopathological development, with frequent positive results. Here Olds' longitudinal research was amply convincing of the role of home visiting by nurses during the first two years of life (Olds, 2006). It became evident to me that this whole movement was much more subtle, did not have the support of the industry, and consequently did not seem to have the influence it deserved.
It is fascinating to note in these three recent books that they all cite research which shows that psychotherapy in its diverse forms brings results at least as interesting as pharmacology. It reminded me of a significant conclusion to which I came in my own work : the importance of the relationship established between a therapist and his patient - this is particularly true with children and families. In my reflections upon changes obtained by nurses and paraprofessionnals with young mothers in disadvantaged areas (Gauthier, 2011), I came to the conclusion that a trusting relationship was the most important factor of change (see also Stern, 2006, about this question).
What I found missing however in the books' conclusions is what I was suggesting earlier : we now have evidence that the early environment has a deep influence on what happens in adolescence and early adulthood, and that early intervention is a powerful instrument of prevention and therapeutics. As a profession we are too hesitant in putting more resources in such early work - it took me almost 10 years to convince my colleagues to have a 0-5 year-old clinic in our Department!
We are living in a completely new world: "Science is inexorably moving us from a focus on the mind to that of the brain" (Drell, 2007). This shift is accompanied by another one that is equally important and a consequence of the DSM IV: we are instructed to look and be interested only in symptoms, present in the behavior of the child, without any emphasis on the context in which the behavior is happening or on the history of this behavior. We can also observe that as in adult psychiatry fewer and fewer child psychiatrists are practicing psychotherapy. In working on my book I had a strong feeling that this powerful movement was in a process of completely dominating the scene. Colleagues are now telling me that the wind is turning : could these 3 publications be the sign of a change in our field?
Research is significantly positive in all domains of psychiatric activity. Psychopharmacology has to be utilized with children and adolescents with a measured vigilance. We also know much more clearly that the quality of the early environment has a prominent role in the development of a child, and that environment continues to influence development all through the years, particularly through the activation of genes (epigenesis). There is no choice : We have to integrate all this new knowledge. We have to rediscover the unicity of the human mind. "The causal effects of nature and nurture on development are simply not separable" (Keller, 2010).
Angell, M. (2011). The Epidemic of Mental Illness : Why? The New York Review of Books, June 23, July 14, August 18.
Carlat, D. (2010). Unhinged : The trouble with Psychiatry - A Doctor's Revelations About a Profession in Crisis. Free Press.
DRELL, M.-J. (2007). The Impending and Perhaps Inevitable Collapse of Psychodynamic Psychotherapy as Performed by Psychiatrists, Child and Adolescent Psychiatric Clinics of North America, 16, p. 207-224.
Gauthier, Y. (2009). L'Avenir de la psychiatrie de l'enfant. Le parcours d'un psychiatre d'enfant. Toulouse : Érès.
Gauthier, Y. (2011). Child analysis in a changing world. In the face of a paradigm shift from the mind to the brain: can we meet the challenge? Infant Mental Health Journal, in press.
Kirsch, I. (2010). The Emperor's New Drugs : Exploding the Antidepressant Myth. Basic Books.
GROSSMANN, K.-E., GROSSMANN, K. & WATERS, E. (2005). Attachment from Infancy to Adulthood : The Major Longitudinal Studies, New York, The Guilford Press.
Keller, E.F. (2010). The Mirage of a Space between Nature and Culture. Duke University Press.
OLDS, D.-L. (2006). The Nurse-Family Partnership : An Evidence-Based Preventive Intervention, Infant Mental Health Journal, 27(1), p.5-25.
STERN, D.-N. (2006). Introduction to the Special Issue on Early Preventive Intervention and Home Visiting, Infant Mental Health Journal, 27(1), p. 1-4.
Whitaker, R. (2010). Anatomy of an Epidemic : Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Crown.
1 Life Member, Canadian Academy of Child and Adolescent Psychiatry; Emeritus Professor (Child Psychiatry), University of Montreal
2 'The Future of Child Psychiatry. A Child Psychiatrist's journey'. I am currently in discussion with an American publisher for a translated edition of this book.
Last updated October 2011.