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by William R. Beardslee
Little Brown & Company, 2002
Review by Jack R. Anderson, M.D. on Feb 12th 2004

When a Parent is Depressed

     This is 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."

     In his 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."

     Beardsley 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."

 

     Chapter One, "Beginning the Journey" lists six steps or stages of family treatment:

1.      Sharing a history together

2.      Bringing knowledge about depression and resilience to bear on their own unique circumstances

3.      Addressing the needs of the children

4.      Planning how to talk to the children

5.      Breaking the silence together as a family

6.      Continuing the family dialogue

     The next 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 medication.

     There 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.

 

     "Resilience" 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:

1.      Becoming separate. Children learned that they were separate from their depressed parents or siblings and were not responsible for their feelings.

2.      Putting experience into words. As they became able to verbalize their problems, they could better understand them and make realistic plans to deal with them.

3.      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.

     Chapter Ten, "Jesse," subtitled "Becoming the Author of One's Own Story,"  illustrates the author's concept of how resilience develops over a long period of treatment.

     Beardslee 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.

     For 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 to understanding.

     His 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 the experience.

     Beardslee 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.

     "How 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.

     In his 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.

 

     In two sections of the "Epilogue," Beardslee provides some cogent arguments for a complete overhaul of the American healthcare system.

      In "The 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.

     In "Core 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.

     Beardslee's 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.

 

     I 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 feel.

 

         

 

 

© 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.