When Carl and Vicky, parents of four-year-old Leila, experienced a recurrence during their recovery from an opioid use disorder, they struggled with how to explain the change in living circumstances to their daughter when she moved into her grandmother’s apartment. Carl’s proposal to tell Leila “we messed up” highlighted the role of stigma in addiction, even from the sufferers themselves. At first they settled on simply saying “We’re sick.” In the immediate aftermath of the crisis, this proved to be an improvement over no explanation. The explosive behavior that had brought Leila to my behavioral pediatrics practice subsided. But as the living situation continued to be plagued with uncertainty Leila asked more and more questions. Carl and Vicky showed palpable relief when I brought their battle with stigma out into the open. Freed from the burden of shame, they expressed many creative ideas about how to talk with their daughter.
Families in the grips of substance use disorders can face enormous obstacles in their recovery. In caring for Leila and her parents I felt license to talk openly about stigma as a well-recognized part of the problem. The emotional suffering of parents in a wide range of circumstances may be similarly stigmatized. Subtle shaming of parents may go under the radar yet wreak havoc on families over time. Consider the following story.
Shalonda and Jason, the picture of a well-put-together beautiful couple, came to see me about their three-year-old son Zachary. They were bewildered by his increasing aggressive and emotional outbursts. Their pediatrician had suggested they seek help in “managing his behavior.” At the first visit, Shalonda shared a litany of complaints about Zachary’s uncontrolled aggressive behavior. She was embarrassed when she had to send kids in the neighborhood home from a play date when Zachary had one of his “explosions.”
As I listened to her story, I noticed her husband had a pained, anxious expression on his face. When I gently steered the conversation away from this barrage of criticism to learn about Zachary’s early development, I turned to Jason in an effort to bring him into the conversation. He had not attended any of the visits to the pediatrician and now seemed eager to talk. “The first year was very difficult,” he said. He looked at his wife, hesitating, seeming to look for her consent to go on. She was quiet, but he took this as assent. I sensed that there was a story she wanted told, though she did not want to tell it.
Jason described Shalonda’s “mental breakdown” in the early months of Zachary’s life. But Shalonda had gotten treatment for what they now recognized as depression only when their second child was born two years later. During Zachary’s first years Shalonda was often overcome by rage—yelling and even grabbing Zachary by the arms and shaking him. I would hear more of this story in our work together over the coming months. But at that first visit Jason, also with his wife’s consent, told me that Shalonda had suffered severe neglect as an infant and had been adopted at age two by a family that provided basic care but little emotional warmth.
Revealed in one hour-long visit, we had a story of intergenerational transmission of trauma, which was communicated by Zachary’s “behavior problem.” Shalonda had significant emotional struggles, unaddressed during Zachary’s first two years, that were accompanied by erratic and occasionally abusive behavior toward Zachary. But I learned this story only because Jason was there. He was clearly in great pain as he had watched his wife suffer, and he suspected that Zachary’s current problems might be related to this early experience. But when Shalonda brought Zachary to the pediatrician, she presented her elegant put-together self, and the pediatrician had no idea of this early history.
I worked with Zachary and Shalonda together for several months. While she had not objected to Jason revealing her history, Shalonda remained focused on Zachary’s behavior. We spent a lot of time observing and understanding how Zachary’s behavior provoked both guilt and rage in Shalonda. The years of infancy when his mother had been unpredictable and at times violent toward him had taken their toll on Zachary’s capacity for emotional regulation. As Shalonda increasingly began to trust me and feel safe in my office, she told me, “I see where his behavior comes from.” She knew that she had a role to play. But now, relieved of some of the hidden and debilitating shame, she could begin to accept it and move beyond simply “behavior management” to work to repair their relationship.
When a new life explodes onto the scene declaring with a healthy cry, “I’m here!” how could that not create some form of disturbance? For individuals with emotional vulnerabilities prior to becoming parents, which I would argue is most people, that disruption may have significant effects. Perhaps the way stigma is addressed head on in the setting of substance use disorders can offer us a lesson for all families with young children. If we can normalize the emotional struggles that may accompany the transition to parenthood, we would be better able to engage families in a range of preventive supports and interventions without threat of stigma or shame.