Introduction:
I consider myself extremely fortunate to have been able to practice Child Psychiatry and still find it as interesting and exciting as when I first began. Being asked to write about my career causes me to reflect on many aspects of my life and work.
The Early Years:
My good fortune began with “good enough” parents who encouraged me academically but also, through their own example, promoted an interest in other people and their lives, and in community involvement.
My father left school after grade eight because he was the eldest in his immigrant Irish family and they could not afford to keep him in school. He worked from age 14, ultimately finding an apprenticeship and was able to complete high school during the Great Depression. He felt supremely lucky to find that with his apprenticeship in tool and die making he was able to become a high school technical teacher.
My mother taught piano and played the church organ. She was a most supportive person throughout my growing up period, always welcoming my friends and those of my brother and sister. She befriended many who saw our home as a happy haven. My father was truly humble and could never quite figure why people had been so nice to him as he was growing up. He never entirely understood that it was because he was such a nice person.
The University Years:
Although I began university with the intent to do research in physiology or biochemistry, I realized that spending time in a lab sacrificing animals was not only aversive but not as interesting as I had imagined. While browsing in a second hand bookstore I came upon a book about psychology. This was in the 60’s and so had a lot of emphasis on Freud. I began reading voraciously believing that Freud could help us understand how people think and why they do things. Although the answers were somewhat disappointing it whetted my appetite for the search. My next challenge was to convince my parents that I needed to go to medical school. We agreed that I should finish my BSc. Medical school was interesting but at times made me wonder if I might choose to do something else. However, after my stint of working a year in India with CUSO, I was more than ever convinced that Psychiatry was the most interesting thing I could do.
Although something of a detour, my time with CUSO working jointly in a Tibetan refugee camp and a Canadian mission hospital was a good life experience. Dealing with individuals who have a very different standard of living but who have a positive view of life helped me get a perspective on “needs” and “wants”, something I continue to reflect upon. I also learned to be patient, previously not a strong part of my character. The bus that I took from one site to another was erratic and required standing by the road and waving. Sometimes a bus would stop, but, as often as not, it was full, so I would sit on my knapsack and wait for many hours until there was a space. I was very aware of not getting flustered by time delays but of using this time to think and look at things around me, perhaps a precursor to my later interest in mindfulness meditation approaches.
Early Career and Parenting:
It was not until I had my mandatory 6 months in Child Psychiatry that I really felt I had discovered where I should be, that is, a career as an academic child psychiatrist. Since that point I have had a great deal of support first with a reduced work load when my children were young and then with an opportunity to get back into an academic stream when I returned to the University of Toronto and Hospital for Sick Kids.
While working part-time at the then Clarke Institute, now CAMH, I was the psychiatric lead on a general child psychiatry team. A request was circulated from the Adult Gender Identity Clinic for a child team member to join them in seeing children with GID (Gender Identity Disorder). Although interesting to me (I had had the good fortune to have had a long term therapy patient with GID who had transitioned by this time) it was the interest of the other team members that led to our becoming the Child and Adolescent GID team. We all found these children and their families quite fascinating and I was convinced there was something physical that we could research. When we were joined by Ken Zucker our capacity to examine the functioning of these children and their families really allowed us to develop a complicated formulation integrating temperamental and dynamic factors into our understanding of GID. This journey has been eventful and filled with lots of competing ideas and controversies.
Under Ken’s leadership we made a significant contribution to the field. Our book Gender Identity Disorder and Psychosexual Problems in Children and Adolescents, published in 1995, continues to be the main reference in this area. In an era where much of psychiatric formulation is reduced to the five axes of the DSM, the patients we have the privilege to see through the Child and Adolescent GID clinic, continue to intrigue me with the constant challenge to make sense of complicated family/child dynamics and biological factors.
As part of my interest in developmental psychopathology I became convinced from the beginning of my career that a focus on prevention was worth pursuing even though the specifics of how to do this were not clear. One of my first jobs was as consultant to a therapeutic nursery program (Thistletown Preschool). In this setting I learned how to do behavior management, something not taught in our residency program at that time. I also began to understand how stressful it was to parent young children and how easily things could go off track. It was at this time that my own children were born and so I was much more sensitive to these issues. I also had the good fortune to work with Nancy Cohen, a research psychologist, presently at the Hincks-Dellcrest Centre in Toronto, who taught me a lot about program evaluation. This study was one of the first studies to evaluate a “preventive program”.
Prior to joining the Hospital for Sick Children (HSC) as a full time psychiatrist I had done consulting work with the Children’s Aid Society and with the Syl Apps Youth Centre, an Ontario Regional facility for adolescents adjudged delinquent and placed in residential care. These consultation experiences piqued my interest in the developmental trajectory of children who had been abused and neglected. At the time Sue Goldberg and Klaus Minde had begun to work at HSC with infants exploring the role of attachment in various disorders. Coming to HSC allowed me to learn about attachment in a way that would never have been possible in another psychiatric setting. I had become convinced that none of the prevailing theories of the development of psychopathology either understood biological factors that contributed to vulnerability well nor did they account for why psychosocial interventions as well as biological interventions could both work. Jerome Kagan was beginning to publish his seminal work on “inhibition” now probably better described as stress reactivity. Steve Suomi was following similar ideas in rhesus monkeys.
These were the foundations that led to me attempt to formulate a theory of the development of psychopathology based on difficulties in the regulation of affect, within the context of attachment. My first paper describing this theoretical model published in 1989 in the Canadian Journal of Psychiatry, was really an attempt to see if anyone would discredit these ideas as they seemed overly obvious and therefore perhaps wrong. Over the next ten years the field of stress research confirmed the vulnerability of certain individuals to anxiety and depression and attachment research confirmed the connection between styles of attachment and patterns of affect regulation.
Infant Psychiatry at HSC seemed to offer even more promise for prevention and so it was not hard to convince me, now as Chief of Psychiatry, to work towards developing an initiative that would promote training for community workers involved with parents of infants and young children. With a small grant from a now defunct organization, Peter Sutton, then Head of Infant Psychiatry, and I, surveyed frontline workers in the community involved with parents of young children regarding their needs. This led to the development of the Infant Mental Health Promotion Project, now referred to as IMP, an academic-community coalition devoted to providing education and training about evidence based programs for parents and infants. This coalition, initially led by Rhona Wolpert, has been very successful in advocating for the needs of parents of young children, in creating information materials such as videos and a newsletter, and in running conferences and workshops to meet this need. My role as academic co-chair of IMP was probably the main reason I was asked to become the Community Champion for Early Years Centres in Toronto. This gave me an opportunity to work more broadly in the community and to help diminish the notion of HSC as an isolated academic institution.
My interest in parenting may be seen to emerge from the above account. However, in teaching residents I realized that despite dynamic theories of psychopathology, there were few clear statements about parenting and how to support that. My interests in affect regulation, attachment and prevention led quite naturally, it seemed to me, to attempting to introduce a more specific focus on parenting in residents’ training and to work in supporting the introduction of evidence based parenting programs in the community. This led to the development of The Parenting Alliance, a community-academic coalition devoted to training in evidence-based parenting interventions. Having had the opportunity to see the impact of such programs over time I am impressed at how staff knowledge and facility in supporting parenting has improved as these programs have become widespread.
It was not until I left the position of Psychiatrist-in-Chief and Head of the Division of Child Psychiatry and had a 6 months sabbatical that I had the time to do the research to support my original theory. This led to the publication of my book Affect Regulation and the Development of Psychopathology in 2000. I have been delighted to see how the basic science emerging over the last ten years has lent strong support to this theory.
The Future:
As I look to the future of our specialty I am particularly concerned that we do not lose our understanding of the importance of a psychodynamic approach to development and to the understanding of psychopathology integrating biopsychosocial factors. There are dangers in the assumption that making a diagnosis tells us how to understand our patients and how best to help them.
Although I began a career wanting to become a researcher (and research has been important in my career) I realize that I was temperamentally more suited to being a teacher and administrator. However, residents don’t always know what to do with me. I have been called too “psychodynamic” by some and too “biological” by others. I feel proud of that as I believe that integration of the psychological and biological is psychiatry’s role. I often joke with patients about my own ADHD but do recognize that having a lot of energy has been a helpful ingredient in my work. My interactions with students, staff and patients have made my career very rewarding and continue to do so.
Editor’s Note:
We are once more privileged to have an insider’s view into one of the bright lights of child psychiatry in Canada and on the world stage. Dr Bradley’s peripatetic career is an excellent example of the interplay of life influences, career challenges and intellectual rigor in the midst of controversy and changing times. It is often difficult to integrate teaching, research, and meaningful clinical contact while at the same time reforming institutions and creating new ones; Dr Bradley accomplished all of this with passion and gusto. This snap-shot of her life also illustrates how she is a great role model for young psychiatrists, in particular female psychiatrists juggling the demands of career and family life.
Normand Carrey MD