by William R. Beardslee
Little Brown & Company, 2002
Review by Jack R. Anderson, M.D. on Feb 12th 2004
an extraordinary book written by an extraordinary author. Beardslee shares with
his readers the clinical insights he has gained during thirty years of
psychiatric practice, but he doesn't stop there. He also explains how decades
of experience with the inadequacies and inequities of the American health care
system have led him to a set of core principles for changing our care system.
Two of these principles are "…mental health care and physical health care
are inseparable." and "…we must have universal access and universal
coverage for both mental and physical illness, for all adults and children."
Introduction, subtitled "A New Way of Helping Families," the author
stresses that the benefits of his treatment method are not achieved in one or
two sessions, but instead by continuing the treatment program over a period of
years. He describes a study of 275 youngsters from 143 families, in which most
of the families were seen for four years and many for even longer. These
studies of depression have convinced him that pessimism about family treatment
outcomes is not justified. He notes: "Many children raised in the most
challenging of circumstances overcome their difficulties and become remarkably
healthy and happy adults."
shares with us some personal history related to his interest in family
treatment for depression. His older sister was profoundly depressed and
committed suicide. In his words: "As I have struggled to help families
make sense of their experience, I have also struggled to make sense of my own."
One, "Beginning the Journey" lists six steps or stages of family
Sharing a history together
Bringing knowledge about depression and resilience to bear on their own
Addressing the needs of the children
Planning how to talk to the children
Breaking the silence together as a family
Continuing the family dialogue
thirteen chapters of the book are devoted to discussions of these six steps and
to addressing the problems that arise during the various stages as the program
continues over the years.. In addition to the family sessions, Beardslee
recommends other forms of concomitant treatment be considered; for example,
Cognitive Therapy, Cognitive-behavioral therapy, Interpersonal therapy and
are no generalities in these chapters. They are filled with specific problems
of specific children, and specific parents in specific families. I didn't count
them all, but there must be more than fifteen different children discussed at
various stages of their development, and nearly that many sets of parents.
is a word that occurs frequently throughout the book; Chapter five is entitled "Resilience
in Action." My dictionary gives two meanings for the word: 1. "the
capability of a strained body to recover its size and shape after deformation
caused esp. by compressive stress" and 2. "an ability to recover from
or adjust easily to misfortune or change." The author describes how the
treatment processes he describes contribute to the development and
strengthening of resilience in developing children. He lists some of the steps
along the way to attaining resilience:
Becoming separate. Children learned that they were separate from their
depressed parents or siblings and were not responsible for their feelings.
Putting experience into words. As they became able to verbalize their
problems, they could better understand them and make realistic plans to deal
Developing relationships. As separate individuals, children were able to
maintain their own points of view and at the same time appreciate the
viewpoints of significant others.
Ten, "Jesse," subtitled "Becoming the Author of One's Own Story,"
illustrates the author's concept of how resilience develops over a long period
first saw Jesse when he was eight, one year after his mother's suicide. He had
begun showing sporadic symptoms of inappropriate anger and his friends and
relatives were concerned that this might be symptomatic of Bipolar disorder,
the disease from which his mother had suffered.
several years, Jesse would visit regularly with his therapist, but refused to
talk about his mother's death. A year and a half after beginning therapy, Jesse
became upset when he learned he needed glasses, and was able to link this to
the fact that his mother had worn glasses and that both her death and the need
for glasses made him feel he was unjustly singled out for adversity. He was
able to talk about this sense of injustice and the verbalization gradually led
father remarried when Jessie was eleven, and Jessie had to deal with his
step-mother's reorganizing and redecorating their house. Until then Jesse and
his father had kept the house the way his mother had left it as a shrine to her
memory. The changes made by his step-mother were difficult for Jesse to
tolerate, but he learned to accept them and was stronger, more resilient, for
continued to see Jessie until he was eighteen. During this time, many crises
had to be faced and resolved, including a breakup with a young woman he had
fallen in love with in high school. He gradually learned to solve these
problems without therapy, by talking them over with himself and friends.
Jesse managed," writes Beardslee, "is not just the story of an
individual but also of his family, his school and his community, all of which
gave him a great deal." This is just one instance of Beardslee's messages
that mental illness--and indeed all illness--is as much a concern of society as
of the individuals within that society.
last conversation with Beardslee, Jesse said that he had made his peace with
his mother's death and that the experience had actually toughened him. The fact
of her death had forced him to mobilize his adjustment resources and made him a
better person than he would otherwise have been. This insight of Jesse's
reminded me of Scott Peck's discussion of "The Healthiness of Depression"
in his book "The Road Less Traveled." Peck also believed that a
patient's depression provided the therapist with the opportunity for helping
the patient complete a growth process.
sections of the "Epilogue," Beardslee provides some cogent arguments
for a complete overhaul of the American healthcare system.
Need for Reform of Care Systems," he notes that our current system does
not even cover all of our citizens; that a large percentage of clinicians' time
is diverted from patient care to deal with over-regulation, for example
negotiating almost daily with insurance companies over the number of
days-in-hospital allowed; and that real spending on children's mental health
declined between 1990 and 2002.
Principles for Change," he states "The fundamental commitments to
equity, justice and fairness that bind us as a country should be reflected in
the way we care for illness." He also reminds us that other countries who
spend a much smaller percentage of their gross national product on health care
than we do rank far above us in the health and longevity of their citizens.
arguments seem to favor some form of socialized medicine and will certainly not
resonate with the huge, for-profit "mediglomerates" that control an
ever-increasing portion of our current healthcare system. However, they will
find support from many economists who believe that health care should be
considered a public, rather than a private good, since we all have a vested
interest in each other's health and continuing productivity. And economic
principles specify that public goods should be regulated by the government, not
by the marketplace.
believe there is something in this book for everybody, whether or not we're
depressed, and whether or not we favor socialized medicine. If we study Beardslee's
words carefully, we will realize that we have more choices than we thought we
did about who we are, what we do and--perhaps most important--even about how we
2004 Jack R. Anderson
Editor's Note: This book was originally published under the title Out of the Darkened Room: When a Parent is Depressed: Protecting the Children and Strengthening the Family
Jack R. Anderson, M.D. is
a retired psychiatrist living in Lincoln, Nebraska.