Psychiatry & Psychotherapy Podcast - Bruce Perry on the Healing Power of Human Connection and Resilience in Trauma

Episode Date: May 9, 2024

In today's episode, we talk with Dr. Bruce Perry who co-authored, The Boy Who Was Raised As A Dog, Born For Love: Why Empathy is Essential and Endangered, and What Happened to You? Conversations on Trauma, Resilience, and Healing (2021). We are also joined by Megan White Zappitelli, M.D., a child and adolescent psychiatrist, and Maddison Hussey, M.D., a child and adolescent fellow.  By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, welcome back to the podcast. I am joined today with Dr. Bruce Perry. He is Professor Adjunct of the Department of Psychiatry Behavioral Services at Northwestern University in Chicago. He co-authored, I would say one of my favorite books that a psychiatrist has written called The Boy Who Was Raised as a Dog. I read that one as a Resident, and it was really meaningful for me. It spoke to my love of connection, my love of just, a hopeful message that damaged brains can change. And he subsequently wrote, born for love, why empathy is essential and endangered. So we're both empathy fans. And then subsequently, he wrote with, who is that name of that famous person? I don't know anyone would know.

Oprah, he wrote with Oprah, what happened to you? Conversations on trauma, resilience, and healing. He has published over 500 journal articles, books, chapters, scientific proceedings, and is, I would say, a thought leader in trauma. He, I would say, is probably high openness on the big five. He seems to creatively look at problems that we face in psychiatry, so it's going to be awesome to have them on. Also, with me is Dr. Megan White Zapitelli. She is a child and adolescent psychiatrist who is connected with Bruce Perry. and teaches one of my former medical students, Madison Hussey, who is also here. She's in Child and Adolescent Fellowship and one of the best students I've worked with them in the past.

And so it's fun to bring her on and see her again. So yeah, let's just jump right into it, Dr. Perry. So I'm maybe just to kind of help our audience, because you have a very unique journey from child and adolescent psychiatry to frenzically trained, child and adolescent psychiatry. interest to, you know, taking cases, working with patients, but also kind of like writing books and getting into that. So how would you kind of help us help the audience know your trajectory and how you got interested and sort of fascinated with trauma? Well, first of all, please call me Bruce. And I have had quite an interesting journey.

And I, for a lot of people, when you look at the different things that I've had an opportunity to do it, it initially seems kind of disjointed. But for me, it's all has a coherence because I've always been very, very interested in history and development and biology. And I, in fact, I grew up hunting and fishing and studying, you know, basically how animals work, you know, how they, where they're going to be, when to expect them to show up, when to expect them not to show up, whether you're fishing or hunting. And then you just, you develop kind of an appreciation of the dynamic of the natural world. And I was also very much a history buff. I love to read history. So I was always aware of the fact that the current circumstances had antecedents that led to the present moment,

whether you're studying history or whether you're studying biology. And I just kind of took that mindset into college. And I was just lucky enough to get randomly, I think, assigned to a freshman seminar at Stanford where Seymour Levine was the mentor. And for those of you who don't know, Seymour Levine was a pioneer in psycho-neuro endocrinology. And he's the guy who basically determined that very early stress profoundly changes the neurobiology of the response system of the brain. And so he was studying this in animal models, really just as I started my undergraduate training.

And so from the moment I was formulating my worldview about how to be a scientist, how to be a biologist, I was aware of the fact that early developmental experiences have profound impact on how you function as an adult. And I just was interested in that and studied the brain. and it was very lucky to have a number of mentors that in the neurosciences when I was in college and then when I went into medical school, I still had a lab where I was studying the development of the stress response systems in the brain. And again, looking at how those stress response systems would change if you had a tiny

little early developmental insult. And sometimes it was stress. Sometimes the insult was a drug. But these were drugs that kind of worked on the systems involved in the stress response system, right? So those of you who are in medicine, you know, you'd probably heard of norpenephyran, dopamine, serotonin. And these are some of these really important neurotransmitter networks that are involved in a lot of functions, but also are kind of the backbone of the stress response. And we would manipulate these systems very early in development and get very different

changes in the functional properties of the animal. And so they would be, have an increased startle response or they'd have abnormal exploratory behavior, that have abnormal sort of sexual behavior and that kind of thing. So that's kind of where I started my neuroscience journey. And then again, I think it's interesting because psychiatry for a long time has had a heritage of building its sort of worldview around analytic perspectives. And then that started to get pushed out with sort of modernization and of psychiatry. And so by the time I was actually training in psychiatry, the psychoanalytic perspectives had been kind of sidelined.

And there was this centering of what they called biological psychiatry because they were measuring some biological thing, right? They were matching CSF or they were trying to do neuroimaging or whatever. They were measuring biology, biological things, but they were not very dynamic. So, for example, they'd take a group of schizophrenics and they'd measure something and take a group of people that were around the same age and age matched and measure the same thing. And then if there's a difference, they go, oh, well, that's what causes schizophrenia. And really, now we know that that's not exactly it.

It's a lot more complicated. But so our work, my work started up being very developmentally focused when I was doing clinical work. And that really brought in a lot of our neuroscience thinking. And so as I started doing this, it became clear that a lot of the children that we were seeing in the clinic, and a lot of the kids that were referred through the juvenile justice system or the child welfare system, had had these. developmental insults early in life. And I kept thinking, well, this somehow has to be relevant to their current functioning. And that's kind of why I ended up studying this stuff. And then over time, what we were starting to just sort of observe and write about

was something that was potentially relevant for law enforcement. And then the courts and then early childhood educators. And so all of these different areas would reach out to us and see whether or not we could help them better understand the children and the families you're working with. And that's kind of why I've ended up with all of these different opportunities. Okay. So, yeah, let's talk about these developmental insults. So on the podcast, we've recently gone through adverse childhood experiences where we did like a couple hours on it so far. and one thing that's jumped out at me is that a lot of mental health issues, a lot of physical issues, almost like double in risk, right, with a couple ACEs. But it seems that there's a couple diagnostic categories like dissociation issues, which is kind of as a broad category, borderline personality disorder, complex PTSD, which significantly increase with, you know,

as the number, the cumulative traumas increase. And I'm curious your thoughts on how you see that taking place, specifically with like dissociation, borderline for a size disorder, complex PTSD. Well, I guess I should probably give a little warning up front. I'm about... I kind of think I know what you're going to say, and I'm okay with you challenging the diagnostic crisis. criteria is or the way that they look at things. Yeah, go, but go ahead. So first of all,

you're pointing out something that's very true, right? When you use our traditional diagnostic categories, then you sort of look at the number of people who have those issues and get a good history. You find that they really have high rates of adversity. And actually across the board, this is true, right? I mean, if you look at depression, if you look at schizophrenia now, If you look at just about any of our traditional neuropsychiatric disorders, the ones that basically fill our public clinics, there's very high rates of adversity in almost all of those categories. Now, there are always examples of individuals who you can't really find an obvious developmental adversity. So it's not, again, I think this is an important part of the trauma narrative is that not everything's from trauma.

And I think it's important to be able to sort of say that. But then once you say that, it is important to recognize that developmental complexities, whether there are attachment problems or intrauter and alcohol or exposure to domestic violence or any number of things that are not traditional aces, for example, even being marginalized and excluded at school, all of those things will alter the functioning of these fundamental regulatory systems in our body that impact many of the systems that are related to affect affect regulation, attention, sort of anxiety-related functions, and so forth. So again, the research is showing, for example, that when you look at the neurobiological

abnormalities, there's kind of a core set of abnormalities that cross all the diagnostic label. And so I think that people are beginning to recognize that there are these, that the original intent of like the DSM to try to figure out what we have in front of us, because it's very complicated, that once you kind of get past some of the original descriptive labels, you start to get into a very complex cluster of heterogeneous problems. And so what we think, for example, is. that if you have profound relational attachment issues early in life, it's not at all surprising that you'll end up with a worldview that kind of gives you borderline behaviors in relationships. If you have inconsistent, unpredictable, early relational experiences, that gets internalized.

And depending upon the frame of reference you want to use, you'll end up with somebody who has a real, real trouble with intimacy. You know, they really long to be connected, but if they can't control that interaction, then they're going to push you away and in ways that are particularly unhealthy. And so that dynamic is interesting. When we first started looking at the neurobiology of adult combat, adult PTSD when I was training at the VA, we were doing some of the first work on this. Steve Selfwick, who's now passed away was one of my clinical mentors. And I said, listen, Steve, a lot of these borderlines,

they remind me of, like, combat veterans in the way they react. And so we literally looked at alpha-2 receptor functioning and alpha-2 receptor issues. And they were very identical to the combat PTSD veterans. And again, it sort of showed that there's this physiological reactivity. It manifested in a slightly different way, and it was probably originated from different causes. But those core systems, you know, these systems in our brain that are involved in our regulation, norpenephrine, dopamine, serotonergic, these kind of core regulatory networks, they're very malleable, right? You know, and this is kind of neuroplasticity is a beautiful thing. But the malleability of these systems is such that if there is an unpredictable activation, the same. The same thing, the same thing, the same thing,

systems will start to ramp up their baseline level of activity. And you end up, even if you haven't had a big ace, if you have lots of unpredictable, ongoing chaotic activations of your stress response system, you're going to end up with a physiological presentation that looks just like, you know, combat-related PTSD, not in every area, but in some ways. And so this is something I think is really important, particularly around inequity and around race and around being excluded and around bullying and around a lot of other topic areas that are, you know, coming to the forefront of the mental health field, that it really is if you walk around an environment and you're continually getting nonverbal cues from people that you don't belong there, that, you know, who are you to answer this question in class? Like microaggressions, right? Yeah, exactly.

what people are calling these microaggressions. These things are the kinds of experience that will cause a sensitization of these systems and then functional problems, which include, as you pointed out before, Dr. Puder, the increased risk for physical health problems. So when you look at hypertension, heart disease, lung problems, and all of the physical health risks, diabetes in marginalized peoples, I think it's related to the same mechanisms that abortions, abortions, borderline is relationally super sensitive and overly reactive. Anyway, I'm rambling. I'm sorry.

I didn't mean to... No, it's good. And you can call me, David, if I can. Okay, sure. Yeah, okay, so there's this common dysregulation that's going on in a lot of these groups. There's like a... And I'm curious how you would define that, like, dysregulation versus dissociation. There's the hypervigilance, and then there's the dissociation.

and like how would you separate those things? Well, I'm glad you asked that so I can kind of clarify this to some degree. So we have these systems in our body that allow us to cope with stressors that we all have kind of heard about and read about. Everybody's heard of the fight or flight response, you know, you get some sort of external threat or internal threat and you activate your autonomic nervous system and kind of prepare for, you know, either fleeing or fighting.

and that's this activation. The, the, an important thing to remember, though, is that your body has this tremendous flexibility in how it responds to stressors. So depending upon the stressor, if there's an internal perception, you know, this and all of this is sort of done out of your consciousness. But if it's clear that this is a situation that is unavoidable, and you're not going to win the fight and you're not fast enough to run away, your body uses other adaptive strategies to keep you to increase the probability

that you'll survive the event. And that involves dissociation. So when you're sitting in a really, really, really boring lecture and you cannot get out of it, guess what you do? You dissociate. You literally retreat to your inner world, you daydream, you think about this,

you think about that, you look at people, make up stories of, about what their life is like, you do not watch, you know, the 553rd slide about hospital safety that's mandated every year, right? I mean, it just kills you. So you dissociate. Small death.

It's small death every year. It is. I know. It's like, oh, my God, again, I did it last year. And so we have these wonderful mechanisms, and we use them all the time. So the neurobiology of kind of fight or flight, we use every day, right? But we don't go it all the way to fight or flight. We just sort of activate it so we can be focused on traffic.

Like, oh, my gosh. Or we use it dissociate when we're in a boring, you know, conversation with somebody like, oh, my God. So we kind of go in and out and we use these complementary networks. These systems help us. But both of those systems, if they're activated in prolonged, extreme, or uncontrollable ways, unpredictable, uncontrollable ways, they get sensitized. So you can develop a sensitized dissociative neurobiology,

which means that when you're confronted with a typical stressor that you and I might manage pretty easily, these folks will literally just to really take a deep dissociative tune-out. And just like if somebody has a sensitized sort of neurobiology the fight or flight system, and they get in a tiny little frustrating interaction, they'll blow up. And so both of these systems can get sensitized in, depending upon the nature of your history. And again, what we see with really complex situations is that many, many of the young kids that we work with have had certain situations where they have been, if you will, maltreated or traumatized

in an inescapable way, and then they'll have had some other experiences where they will have been able to use the fight or flight. So there'll be some evocative cues that will make them blow up, and other evocative cues will make them shut down. And you may or may or may not remember this, but there was a time in psychiatry

when there was a thing called rapid cycling bipolar disorder. And they would have these kids. 90% of them had histories of profound developmental abuse, but they would be literally act like completely out of control, manic-y, and then 24 hours later they'd be completely shut down. And using kind of the lens of the DSM, right? I can see where people would go, wow, that's manic and then that's depressive. And this is like this weird rapid cycling thing.

But it was at least in every case that I saw where I was asked for a second opinion, it was explainable by these sensitized stress response systems. Yeah. I'm still seeing these, by the way. They're still coming at me. Now they come with the diagnosis. I'm bipolar, Dr. Puder. This is why I'm bipolar.

I get angry all of a sudden. One minute I'm angry, the next minute I'm not. It's like, you know, I still see this quite a bit. You know, and the thing, David, that's so interesting about that is that if you back up a little bit, and think about the evocative cues that elicit that. And if they're relational, right? If they're relational, that kind of fits that borderline presentation in a little bit of a flavor.

So. Yeah. Okay, so thinking about the dissociation, I'm curious, what is your take on like kind of the polyvagal theory and how, Porges talks about dissociation, fight or flight, those sort of dichotomies.

Do you think that's helpful to you? It is helpful. I mean, it's interesting. Everybody who's like studying all of this stuff, whether it's Bessel or, you know, Porges or Dan Siegel or any gubern, all the people that are kind of the people that write about this, everybody's trying to grapple with incredibly complex stuff. and so we're all reduced to creating some simpler working model.

And the question is, there's a couple of things happen. One is that as you reduce the complexity and create this simplistic version of how to understand stuff, do you continue to recognize that it's a model, you know, as opposed to become a true believer that, oh, there's one. one nerve that controls everything. And it's like, no, I know he doesn't really believe that way. But what happens is there are people that hear what he, hear him talk or hear what he writes about, and same with my stuff, too.

You know, they'll take it, and then they'll kind of try to fit it into their worldview. And then they, then that third version of simplification becomes a distortion. And so I do think he's done some incredible research. And I do think that a lot of the stuff that he's written about is really high-quality thinking. But I also think that no single model explains everything. And that goes for our stuff, the stuff that we do. You know, we human beings are just way too complex. And so I do think that for a lot of people, it's very helpful to think about that, sort of the yin-yang thing.

It is true that there are parts of the vagus that sort of are, you know, will have a different effect than other parts. But I also know that there are parts of the central nervous system that are involved in this. Yeah. You know. That's been my take. One is I tried, well, I did some research on medical students where we hooked them up with the heartway monitor and stuff and we're looking for, you know, are they in the, what vagal

state are they in? Are they in a fight or flight or, you know, how stressed out are they? And in talking to his researcher that was working with him, you know, there was like, well, there's no way to measure this like dorsal vagal place, this, you know, dissociation place with the heart rate, which was disappointing to me because I was like, wait, how do you measure? If you can't measure it, does it exist? Yeah. And so then I think of like the third category, like that shut down dissociation as a broader category, which involves the brain and obviously the whole body. Yeah. And I think that's kind of where you're at, too. Yeah, I mean, I, I, I, we used heart rate initially to kind of look at dissociative dominant versus hyperalza dominant.

So, you know, we had fun, had some interesting findings. And it sort of, it intersected with a lot of the people that were doing work on the callous, sort of antisocial, development of antisocial personality. Right. Yeah. So, wait, so what I think what you're saying there is like the someone who's psychopathic, they're going to be less. reactive. Right. That's what you're saying.

And they have the same kind of physio. I don't know if you know much about cats. But cats, when they get into this predatory mode, they have this physiological disassociation, basically, where they actually everything tunes out except the prey. And so that's highly adaptive, but it's a predatory behavior, right? And so when we haven't a long time ago when I first started doing this, I noticed, I mean, I kind of stumbled into some of this stuff by working at a residential treatment center where there were like a hundred kids there. Failed that on average eight previous placements had had on average like 15 previous evaluations. And they were in this residential home and they're all in the child welfare system. And so I was the doctor there as a consultant.

And I'd go in and I'm like, oh my God, these kids have, like, their resting heart rates are 120. And I thought, God, they have hyperthyroidism. And I looked in and they didn't have hyperthyroidism. But they had anemia. Almost all of them had an anemia. But it was the anemia that you get in the, when you're like an ICU anemia, when you're sort of high resting heart rate forever, you're basically wearing, it's like wearing out your tires on a road. And so the blood cells were, like, moving through their body fast, fast. you know, 40% faster than normal.

And so they were wearing out. And they just weren't, you know, making them. Oh, wow. So anyway, so there was a bunch of things that we were seeing. There was, however, a subgroup of these 100 kids, about 12 to 14 of these kids, had low resting heart rates of about 60 beats per minute. And they were all clinically much more.

These were the kids that would steal things, with no rationale. You know, they just, for whatever reason, they didn't need any more buttons or, you know, pencils from the teacher. They just would steal shit. And it took us a long time to kind of figure this out. But these were the kids that were very predatory.

They watched other kids. They set up other kids, their behaviors. Whenever they had an incident that involved aggression, it was always targeted aggression. It was never sort of the kind of aggression that we saw with the other kids that would be like, you know, you're in the lunch line and somebody bumps you and goes, look, you know, and you have a big fight. That kind of reactive stuff was from those kids that were tuned up. The kids that at the low heart rates were the ones

that were more predatory. So, and this is something that other people have seen and written about it. Right. Ted, Ted Budney, uh, at some summer camp when he was a kid, built a hole and put stakes in it. You know, he was doing this decades before he was ever abducting women. I also think about, like, you talked about this, in your first book, this boy, or these kids that were taught to talk about how they were satanically, richly abused by some very off social worker or something like that. And you measure their heart rates as they talked about the stories, and their heart rates did not show a normal stress response. You want to mention that? Because that seems so well. Well, we had been exploring the use of, you know, cardiovascular responses as potential markers for certain kinds of things.

And now, as it turns out, and let me just proceed this, as it turns out, and this is one of the reasons I think that you got the feedback from that researcher about heart rate and dissociation, particularly kids where there's complex, you know, if you have a sensitization of the system, that makes your heart rate go up and a sensitization of the system that makes your heart way go down, most of the time you're going to measure a heart rate that's right in the middle. Like, you go, there's no abnormality. But what if you track those people over time, what you find is their dips and their peaks are just way higher. So their heart rate max and their heart rate min are just huge. And then heart rate variability is a little bit different. So the reality is, the reality is, though, you need really, really sophisticated sort of biometrics to be able to get at that.

So we've discouraged people from using the kind of simple heart rate stuff that we were using in the beginning, because it can lead the lots of misunderstanding. But one of the things that we were doing at the time was there were a group of kids that had been literally tortured into false confessions that they were part of a satanic cult. And what I mean tortured, they were literally, we've got videotapes of them being asked and asked and asked and asked and having a holding technique where they're held and they mobilized. Awful. And their chest, knuckles are running to their chest. They're wetting their pants.

They're, and finally they start, they realize that they'll say, if I say what these people want me to say, then they don't hurt me anymore. So these kids were making these confessions. And so when I talked with them, and I had, we had other. We had evidence and data from other kids when we would ask them about something that was real, that was really traumatic. They would have some kind of physiological reaction. It was either a drop or it was, you know, depending upon kind of how they coped with it. But there was a response. And then when I finally got to the point where I was tracking their heart rate and I was doing a forensic interview with them, there was nothing.

You know, there was like, you know, tell me about how you, you know, killed Billy and took his brain out and cooked it. Because that was one of the things that these stupid, I'm like, have you ever tried to cut a brain out of a human being? I mean, can you imagine an eight-year-old kid? No, you didn't have, you can barely do it if you've got good equipment and you're a forensic pathologist. I mean, anyway, so the stuff that was, I, someday I'm going to write a book about this. It was the most insane thing you can even imagine. but we used heart rate monitoring to show that, listen, each one of these kids that claimed to have had these horrible things and done to them, none of them had any physiological reactivity. However, when you ask them about staying with these foster parents that were torturing them, then they had physiological reactivity.

And fortunately, or they had been dumb enough to record all this stuff. So we were able to show this is what they did to these kids to get these confessions. And this is why they have a physiological reaction to this person and not to say abuse and killing people because they didn't kill any. Anyway. Yeah, that was powerful whenever that I read that. Really, really helpful. It's like they had the reaction towards the supposed helper, the supposed this person who was just very off. Okay, I'm wondering kind of like as we as we think about like attachment issues,

there's been some research, a lot of research on like mentalization based therapy. And specifically they found that kids with low reflective function who then have a trauma go on to develop like borderline precise or there's like it seems to be like the mediating factor of if they have the low reflective function, they're at increased risk. And low reflective function is measured by the, well, in adults it's measured by the adult attachment interview. And it's looking at their ability to know their internal thoughts, their attachment figures, internal thoughts. And so I'm curious if you have any thoughts on that, if that's something you've paid attention to, research-wise. Well, first of all, can I, I mean, do you guys want to talk, Maddie and Megan?

I mean, we're going to get them to jump in. Please, please jump in when you have thoughts or questions, yeah. Yeah, I mean, I did have questions, but I don't want to, I didn't want to stop you either. I did, like, really quick, though, have a question about when we were talking about, like, antisocial personality and that, all of that. Do you think it makes a difference based on, like, when the trauma occurs as to, like, if it'll develop into antisocial versus, like, borderline? like I'm wondering, like, based on how old the kid is, because I remember the one story that

you wrote about that really sticks with me is that one, that one boy who was neglected, just like as an infant, like, from day one and had like a really antisocial personality versus, like, other kiddos who don't really go that route. Yeah, well, that's a really good question. And it's something that we're trying to learn more about. in general, what we're seeing and what kind of fits with our working hypotheses about this is that if you have significant relational neglect early in life when you're sort of first creating your mental map, you know, your worldview about human beings, you're much more likely to have

higher risk for some of these unhealthy, you know, personality problems. If you create a jet, in some of our research, it hasn't looked at that specifically, but it's been, it kind of confirms the power of these early relational experiences and shaping, you know, these, your working model of the world. That if you have a pretty well organized initial positive set of relational experiences, you can tolerate a lot of crap later on. and this is why we talk about why it's so important to take care of young families, young mothers in a lot of ways. You know, their housing, their health,

their relational experiences and so forth, that that really is huge bank for your buck down the road. But David, speaking to your point, kind of taking off from what Maddie was talking about, is that we think that the development of the development of the capacity to be reflective about others and sort of higher order, cortically mediated capabilities like mentalization, that those are related to the opportunities you have to kind of have

normal cortical organizationing organization experiences. So that sort of perspective taking, you know, thinking about another person and that kind of stuff that that requires certain cortical capabilities. And one of the things that we know is that if you are very dysregulated early in life and these systems are overactive, one of the things that they will automatically do is interfere with the normal development of these cortical capabilities. So the inability to do the kind of mentalization you're talking about, I might trace back to are there earlier developmental experiences that caused a sensitization

and overactivity of these core regulatory networks that impaired the normal organization and then led to this kind of vicious cycle, which, again, you know, I think everybody, the challenging thing about looking at dynamic systems is that if you just measure two components of that system, you're frequently going to see associations and correlations, but it may not give you a lot of the right insight about causality or about kind of what's the most focal point to intervene.

So would you take somebody who has a difficult time with mentalization and focus on cognitive stuff, or would you make sure that they know how to regulate? Because if you can't regulate, you can't mentalize. There's a public paper that's just published coming out of Ned Kalin's group at University of Wisconsin, and they did a really interesting study, and they looked at cognitive behavioral therapy, and basically came to the conclusion that cognitive behavioral therapy leads to changes in cortical stuff, but it doesn't really have impact on lower limbic and lower systems. And their conclusion was, you know, we probably need to think about,

having therapeutic activities that are going to target those parts of the brain. And again, they're not saying don't do CBT, but it's like CBT, it's hard to get to those lower parts of the brain, particularly if they're really overactive, if you only use kind of cortical routes. Okay, so there's two pieces of information that you gave me when I was really young that were very helpful. Number one was there was a study that you talked about

that inner city kids have a lot less contact with humans and a lot more screen time than higher socioeconomic status kids. I think that was the study. Do you want to speak to that and kind of the impact? No. Am I wrong about this? Well, it might have, it may have been Dr. Hutton Locker's research on number of words spoken to kids who were low-income families. and so when I think it was not as much about relationships as it was about conversational language and so what they found was that if you have exhausted overwhelmed caregivers that come home

and they don't want you know they're just too tired to read and they're too tired to have big conversations they're like eat and you know here's what we have for dinner that the acquisition of vocabulary in the development of language is slower than if you have a highly verbal, you know, group of human beings that are continually narrating, oh, let's go to the grocery store and, oh, look at this, this is cream of wheat. So, I like cream of wheat, I can't always have it. But, you know, the kind of stuff that can happen if you are with your baby and you have a little energy. And so I think that there have been a number of studies about the number of words,

heard in low-income families and the number of words that are heard in families that have higher income. And again, this, that's the, I mean, this is hard to talk about, but one of the things that's been a little challenging with that kind of work is that it easily lends itself to interpretation in a somewhat biased way, and in part because of the way they clumped the folks. I can tell you right now there are lots of inner city poor families where the kids are getting spoken to a lot, and they learn a lot of poetry, and they learn a lot of music, and they learn a lot of great stuff. And it's always kind of challenging when you talk about that kind of older research,

because it has kind of built into it a little bit of a racist perspective. And there are a lot of people are pretty sensitive to that kind of research. I was just talking with my pediatrician about speech therapy, and you actually can not be covered sometimes if you're from a certain educational level.

Like, my son might not be covered for speech therapy based on my level of education, but he's one and a half, and he's not meeting his milestone. So it's like, it totally like flies in the face of like it's just based on education, like whether or not you would need speech therapy. And it's totally like a structural. I mean, I don't want to say that I should get it in front of anybody else. That's not what I'm saying.

But I'm saying like I don't think it's education based like the reason that some kids need it and some don't. Yeah. Well, you know, the thing that's that points out that's so interesting. And again, this kind of goes back to the DSM sort of issue I have with the DSM. is that at some point when you're a researcher, you're always trying to figure out what's a meaningful bucket to kind of divide the groups into. And for a long time, people use socioeconomic class

as a way to divide groups and study them. And it can lead, as you're pointing out, to sort of, it may be a large group trend that you identify, but it really doesn't tell you anything about the individual. And then this is what's really hard. Because human beings tend to create a worldview based upon trends, not upon individuals. And so if you have this internal, this sort of this implicit bias that this little black kid from the inner city is going to have a speech and language problem, that will influence just all kinds of stuff. Delivery of services, the way you interact with them, the way you think about them, the way you treat the mother.

And this is the kind of thing that I think the folks that have been talking about equity, are trying to get us to understand. And I think that these are legitimate concerns because it is a big part of what our model is trying to do. It's trying to back away from clustering everybody into categories and do what we can to understand people as individuals along different sort of dimensions.

I think I took it this sort of idea that the amount of human contacts that you have, the more is better. And there was another study that you emphasize talking about how over the course of decades, there's a decreasing, it seems like almost a logarithmic decrease in the amount of social contacts and humans that a child will be interacting with on a daily basis. So I think you could speak to that maybe and talk about like, I think your emphasis and the passion that I feel is like, Like, our kids, every kid needs meaningful connections with a plethora of people.

And if there are people due to poverty that have a harder time bringing that plethora of people to that child to interact with, like we have to as a society figure out mechanisms of increasing the amount of social contacts. And so that's my heart behind it. And I think that's what I felt your heart was behind. I hope I'm not projecting. No, no, no. You're absolutely spot on. I mean, that was one of the big themes in the last chapter of our first book.

And in really the whole second book, the book about empathy is about the power of, the powerful role of human connectedness and kind of the unintended consequences of modern civilization that have fragmented us, right? Pull this apart. We spend more time in front of screens. We spend less time in communal interactions. Our third spaces in the United States are not very good. Third spaces being places where parks and city squares

and places where people meet and convene in somewhat informal ways. But if you look at the relational density of an indigenous community where there are multifamily, multi-generational groups living together, The amount of physical touch, the amount of human relational interaction is just way, way, way, way richer than in a typical suburban environment where kids grow up in a house and they have their own room and they have a TV in their own room and they have a couple family meals a week and they go to school and they're one of 20 kids in a class or 30 kids sometimes. and that relational, I mean, I use the term relational poverty, that relational poverty makes you physiologically at risk because there's a profound physiological impact of being with other people. And it's a positive impact by and large. Now, obviously, if other people are feeling connected and they feel like they belong and they make you feel like you don't belong, that's a

powerful negative impact that can happen if you're marginalized. But I think that that's your same passion, David, that listen, if we don't understand this and we don't start to create policy and practice and programs that create more opportunities for positive relationships, we can issue every white paper we want. We can come up with the best evidence-based individual practice, but it really is going to be a drop in a bucket. And I think that's part of the problem right now. And I think mental health is really, I think mental health is at a crossroads where there's a lot of people that are that are focusing on the reductionistic perspective, where there's a diatic interaction between somebody

with information and materials and stuff, and somebody who needs help. And the other sort of perspective, where instead of being focused on the diatic relationship, we have to focus on family, community, culture, where I think that's really where the future of mental health is going to go. I just did, in a step in a while ago, but when Turkey and Syria had that huge earthquake, they asked our group to help and provide consultation. And the first thing we do whenever we have one of these big disasters, as we do kind of an analysis of capacity versus need. And so the need of people that were impacted by that earthquake, and those of you who are listening, you can also think about what's the need of the, what are the mental health needs of the people in Israel and Gaza?

I mean, just hold that in your head for a minute. But this Turkey earthquake, there were 400,000 people dead. There's several million people homeless. And so if you use traditional TFCBT or whatever kind of version of C-bits or whatever mental health once a week, office delivery, you wouldn't even be a drop in the bucket.

You'd have to take every single mental health professional in Turkey, Syria, in all of Western Europe, and they would have to work nonstop all day, all week, to meet the needs of those people, let alone the other people they had in their workload. And so it's pretty clear that even if you have a tiny, let's say you have a small catastrophic event in a family where there's a father comes in and shoots mom and kids witness it. If you look at the risk profile of who's going to benefit from, you know, the echo of that, that means you need about 30 hours a week of clinical service time to open up in the public health clinics, public mental health clinics.

Who's sitting around with, you know, a bunch of extra time to do that? Nobody is. And so we really have a capacity problem in our field. And it's not going to get better by teaching. I mean, we should make more of us. That's great. but I think us, we really need to go out and find the strengths and the therapeutic practices and the rituals and the routines that are culturally embedded that have the therapeutic capability to help people deal with this stuff. Because the medicalization of some of this stuff, we're not going to solve it in a clinic.

Okay. I love your outside the box thinking. I really do. And I think we need people like you who are advocating and thinking outside the box. Just one thing you mentioned in there, which I remember as well, is the first person I've heard from recommend parents learning child massage for specifically if they adopted a young child to basically get them, get the child physical touch maybe that they didn't get.

and that that i think that's a i don't know if you still recommend that if you still advocate for this um yeah we have a we have a number of people who are in a variety of different therapeutic activities that are pretty easy to teach parents and sort of recruit them to become you know to do therapeutic work uh all the time so massage we use sport a lot we think music and movement you know we think that we have

a group of OTs who teach a lot of the kind of sensory diet activities to parents and they end up be the ones that can deliver these therapeutically positive activities day in and day out because no matter how great you are as a therapist you know

you see somebody once a week maybe twice a week maybe three times a week and that you know they will need a lot more than what you can give them So we have to figure out how to externalize what we know is good for people and share that. Yeah, so this is this kind of leading into how are you doing this to some degree. You have this neurosequential model of therapeutics, neurosequential network, and that disseminates this information.

Tell me a little bit about that. I know we have like, you know, we have to get you out by. three. Well, if we go back to the beginning of the podcast, I was talking a little bit about the evolution of my, you know, the work that we do. And pretty early on, it was clear that an interdisciplinary group was going to be most effective to kind of address some of these complex issues. Because really, you know, we were really focusing a lot on kids that had been exposed to

domestic violence and other kinds of abuse and so forth. And a lot of them were the kids that ended up in special education. They would end up in the child welfare system. A lot of them were in the public mental health system. So all of the systems that we have, these kids were entering. And we needed people that were from all these different perspectives. So part of what we started to create was a community of like-minded people who were willing to be flexible about the way they do their work in their system. And we developed an approach that really is not just evidence-based, but it's evidence-generating. We have assessment, a standard protocol and assessment process that's web-based, that's built into this assessments, both in education and mental health. And we started

teaching people some of these core concepts that we think are helpful. And not to be prescriptive about use this therapy or that therapy, but really understand the developmental history of the person, understand how they're currently functioning, and then based upon what you see from this assessment, which gives you kind of a rough reconstruction of how well-organized somebody's brain appears to be, you just decide, you select and sequence interventions

and activities and educational services that kind of meet them where they are. So we might have a kid who's 10 years, old chronologically, but who's got the social skills of a four-year-old. And so we don't put him in a social skills group that for 10-year-olds, we put him in a social skills environment to learn what a normal four-year-old would learn. But he still may have some cognitive strength, so we don't, you know, we don't only let him hang out with four-year-olds, and he may have good motor skills. So, you know, we try to put together a constellation of

things that meet the child where they are developmentally. And we started about 10 years ago creating a process to teach this and distribute this. And we were looking at the data just this last week. And we're now, we have about 5,000 clinicians and about 10,000 programs in schools across the world that are using this. And we've been able to get a lot of useful data so we can ask some questions, kind of like, the one that Maddie was asking about, that is relational neglect early, more impactful than it is later? And the answer is yes. But that's the kind of thing that we can look at in a little bit more systematic way. So we're optimistic that we'll continue to learn more. We have to keep reminding

ourselves and reminding other people that this is a model, right? It's easy to kind of get swept up and think, oh, God, we really understand this. But we don't really understand a lot of stuff. And as long as we keep an open mindset as a working group and try to export these ideas with fidelity, I think we're going to continue to see some progress. Do you think you'll ever try to do those studies with adults, like on inpatient settings or like long-term, like residential treatment? You know, we actually do have places that work with adults completely. Yeah. San Mateo County's adult mental health clinic uses this approach.

And then a lot of the stuff, a lot of the places that we work with, they'll do a metric or an assessment with the parent and with the child and then kind of create a joint treatment plan for both of them. And then we have a couple of instances where there's a three-generation assessment where we, you know, we kind of are able to look at transgenerational impact of some of these things. So we've got a lot of, we have a lot to do. And fortunately, we have a lot of great people like Dr. Megan Z. Who are helping us. Well, thank you. Oh, there you are. I want to, I have sound now.

I wondered, I know we have a few more minutes. If you could just weigh in, you know, I did not have the advantage of knowing about the neurosequential model of therapeutics as a trainee. I had to seek that out later. when I just could not write oppositional defiant disorder on one more chart when it just did not make sense and sort of sought it out later. And now I'm as a program director of a child psychiatry fellowship and tasked with the education of future child psychiatrists. And sort of, we know the earlier you learn things, the more likely it is to be part of your template. And so in our program, we learn

NMT alongside with DSM model and medications. What would you say to people, early in their training and then also to educators like me of kind of how to learn these models or use these models in concert with one another. Well, first of all, we're very happy to be able to work with you guys because, you know, we do think that the earlier you start thinking about some of these developmental issues, the more likely you are to fold them into your thinking about problem solving and differential and that kind of thing. And just to be clear, I don't really have a problem with the DSM as long as you are to

as it's qualified, right? Just like, again, I think part of what's happened with the DSM is that a lot of people use it without saying, this is a model. You know, this is a model, too. We're just trying to approximate and cluster these things so we can learn more. Unfortunately, it's become yoked to our medical economic model. And so it's, it's institutionalized in a way that's going to make it less flexible. But, I guess what I would say is the more you learn about developmental issues, the more you recognize that there are contextual factors that play a major role in depression, in schizophrenia, in all kinds of things, the better off you'll be as a problem solver. I do think that more and more people are recognizing that the healing experiences that help people. the most meaningful healing experiences take place outside of the office. And the more we understand that, the more we can build capacity out there. We can support the kinds of things that are going on that are good. We can enrich what works and we can start to sort of minimize the things that appear to be interfering with that. And I think that, you know, will be more effective. But if you really, if you take a community, completely reductionist perspective on mental health and focus on, we just need to find the right

receptor and the right drug to get the right receptor. You just, you are going to be frustrated and probably be going down a rabbit hole because it's, those dynamic systems are so complex that as much as I value basic research and reductionist research, which I think is really important, I don't think it should be the basis for therapeutics. You know, so just learn as much as you can about complex dynamic systems, including culture, you know, including, you know, good old, even like, you know, even if your reach is only as much as like focusing on family therapy or, you know, group therapies or, you know, understanding some of the social context that these things take place in. I think it's, that would be very helpful. Yeah, I just had Bateman and Fonigy who developed mentalization on and they shared that they thought some of the most helpful things they realized was how the work in therapy allowed the patient to interact better outside of therapy. Exactly.

And then those thousands of interactions that happened over the course of years led to great outcomes. you know, five, six years. That's exactly right. And I think that's also the benefit of good psychopharmacology, that if a medication helps you take advantage of a good teacher or a, or a, well-intended, positive social interaction from a family member, then that's the real positive thing about the medication. It's not really made, it's not the medication that's changing the fundamental capacity to form relationships. It's the repetitions that success. It's the repetitions that succeed because you're not blowing up every time you interact with somebody. Now, again, there may be other ways to do that without medications, but that's, you know,

I do think medications can be a legitimate part of your toolkit. Yeah. Great. Any final pearls before we wrap up this time? I know you've got to run to go do some coaching. Yeah, I'm going to go coach my little elementary school. Just, you know, just to keep an open mindset. You know, I think that those of you who are.

young, in 20, 25 years when you look at our field, it's going to be very different than it is now. And, you know, just recognize that many of you have a leadership opportunity in your community and in your system. And there's a lot of good stuff that's happening out there. And you can be part of it. So awesome. We will put all the links to your website. and your books on our show notes and on our website. Thank you so much for coming on. Dr. Perry. My pleasure, David.

Thank you. Dr. Zapitali. Nice to meet you. Good to see you, Dr. Hussein. Thank you. And we'll leave it there for today. See you guys. Thanks.