In the months that followed the brief moment of hope in the spring of 2021-before the surge of the delta variant of COVID-19-in my behavioral pediatrics practice pervasive anxiety of in-person visits felt even more acute in contrast to that small, glorious taste of freedom. As I see children under four with their family for hourlong sessions, the benefits of the mask-free Zoom space soon brought me back to the virtual world. But in the interim I learned a new technique. I asked parents to videotape a moment of their child’s distress so that we might watch it together on the screen. By using the screen share option, parents could stop and start, as we took time to explore the full range of feelings that came up.
My work with Alex’s family offers an example. When they first came to see me with the question of what was “wrong” with their three- year-old son, they focused exclusively on his behavior. They described years of worry that he was “too aggressive” or maybe had “bipolar disorder.” His intense reactivity dated back to birth: they described a baby who “noticed everything.” Consultation with pediatricians and other specialists hadn’t made a dent in the problem. Now things were getting worse; there was a fear he might get kicked out of preschool. Behavior management plans failed to shift the downward spiral of distress into which the whole family, including 8-year-old sister Elena, descended multiple times a day.
It the video clip of one of Alex’s typical meltdowns which we watched together on the second visit, we got right up to the burning flame of the family’s pain. Brian described a sense of helplessness as he listened to his son’s cries of despair in the grip of complete disorganization. We saw the deep sadness on Sondra’s face, strained from the exhaustion of efforts to reach her son. She appeared to succeed for a fleeting moment as Alex tried to catch his breath before her words seemed to set him off into total loss of control. As we spoke about the stress this intense child put on their marriage and their relationship with their daughter, Sondra quietly wept tears of acknowledgement.
I thought of this moment when I read my colleague Suzanne Zeedyk’s brilliant piece Why Professionals are Distressed by Children’s Distress. She quotes the work of James and Joyce Robertson. “Although there is everywhere good will and good intention towards young children… [progress in] work with children stagnates because the common defence against pain allows the acuteness of the problem to be dulled, as [if] by a tranquillizer.”“The major obstacle to suitable care is neither practical difficulty nor lack of knowledge. It is that, whatever level of intellectual understanding may obtain throughout the professions, the appropriate sense of urgency and alarm is missing, or is dampened down.”
Persian poet Rumi wisely said, “The cure for the pain is the pain.” Once we opened up the deep well of unspoken feelings and let them out, the full complexity of the story could emerge. I learned of a multigenerational struggle with profound anxiety. Sondra shared vivid memories of crying alone in her room at night as a young child. Her anxiety re-emerged during her years as a single parent when she and her daughter were never apart, and again in the weeks following Alex’s birth, when she lay awake all night plagued by vivid images of violence befalling her husband and children. What started out as a request to “manage” a 3-year-old’s meltdown led to a deep and complex discussion of sleep, separation, and loss that affected the whole family.
The series of five visits over a couple of months unfolded with the drama and beauty of a ballet. The opening act took place in person with masks and an attempt at a 6-foot distance in an awkward space. While I learned some basic history, the strain was palpable as we struggled to make sense of each other’s perspective. Not only the masks but also the unspoken fear impeded our ability to connect. We met next by Zoom in Alex’s play space where I acted as kind of a film director. I then met with them all together as a family, allowing me to hear Elena’s perspective and opening up an important chapter. The final of four visits on Zoom- with just mom and dad present- concluded with a discussion that hardly involved Alex . When I mentioned this, Brian smiled and offered simply, “That’s because he’s doing great.” Both Sondra and Brian felt confident enough to not make a follow up visit, preferring to leave open the option for a check-in if needed at some future point.
In my professional life I’ve had the privilege to follow my own path, working with families in the way that feels right based on knowledge and experience gleaned from a variety of disciplines typically siloed from one another . For example, when a unique opportunity to build a hospital-based infant-parent mental health clinic collapsed in the face of a new head of child psychiatry who wanted me to do “parent training” for children up to age seven in order to help decreased the “ADHD wait list,” I left. I joined a volunteer clinic where I see only very young children, working with families before the societal pressures to diagnose a problem become too great. We get to play in the uncertainty, letting the consultation evolve without the rigid structure of assessment of the child. We often find ourselves in unexpected places.
In my role as faculty of the University of Massachusetts Boston Infant-Parent Mental Health program. I recently listened to a presentation by Dr. Barbara Stroud in which she placed caring for young children and their families in the context of systemic racism. Describing “voices that have been silenced” she cautioned us to “stop talking, teaching, and intervening long enough to listen.” When a month later Dr. David Willis spoke for the same program about Early Relational Health, he put my struggle with mental health “screening” and “assessment” into a new and interesting frame. Alluding to their judgmental nature, he looked at these constructs as “white dominant cultural products.” He spoke of the need to attend to power dynamics in supporting relational health with a model of promotion and prevention. Both Dr. Stroud’s and Dr. Willis’s language resonated for me with the idea of protecting space to listen to parents and young children from a stance of “not knowing;” to imagine our way into another person’s experience in all its complexity. It may take more time than traditional “screening,” but not that much time. And the alternative may serve to silence more voices.
A novel by Ruth Ozeki The Book of Form and Emptiness captures the problem of “assessment” when a young psychiatrist considers her inability to listen to her adolescent patient’s “delusions” about a book inside his head. She wonders what it would be like to imagining his experience as real. Ozeki writes:
“They were good questions, worthy of consideration, and she wished she could explore them in in her session notes…while she didn’t believe there was a book inside her head, her head often felt like a book, crammed full of stories from her young patients, and she would really like to get them out of there. Writing would no doubt help- Freud wrote his patients’ stories down, after all, and reading his books was what had drawn her to the field in the first place-but this was no longer possible. The days of long, narrative, psychoanalytic case histories were over, and now she barely had time to jot down a brief assessment and treatment recommendations. The hospital, for reasons having to do with litigation, discouraged anything more elaborate, but while it was inadvisable to put her doubts in writing, this didn’t mean she didn’t have any.”
This excerpt speaks to me in many ways. Followers of my blog will know that about a year ago I set out to write a new book. In a post launching that project I wrote, “When I listen to a family, I approach the story from a stance of “not-knowing,” letting things unfold naturally. Even after decades of listening in this way, I find myself repeatedly amazed and delighted by the meaningful connections that reveal themselves. In a similar way. I approach this writing project not knowing exactly where it will go.”
Having played in this uncertainty for almost a year, I now find myself in a very different and much larger space. Between the trauma of an ongoing global pandemic and our country’s reckoning with centuries of oppression and inequity, the scope of the book I originally set out to write feels woefully inadequate. With the great privilege of being brought intimately into the lives of so many families, I feel an obligation to explore what babies and their caregivers have to teach about navigating this unique moment in history. So, I begin again.