An Interview with Dr. Lois Flaherty, Editor in Chief of Adolescent Psychiatry by Dr. Theodore Petti, immediate Past President of the American Society for Adolescent Psychiatry
How do you see the history of adolescent psychiatry? Prof. Flaherty:Although many early leaders such as August Aichhorn, Anna Freud, G. Stanley Hall and William Healy wrote about adolescent development, psychotherapy, and psychopathology, Adolescent Psychiatry as a special field of psychiatry came into being with the founding of the American Society for Adolescent Psychiatry (ASAP) in 1967. This happened during a time of turmoil for young people in the United States and other places around the world, most notably in France and Germany. The 1960s was a time of questioning authority, especially political authority. At the same time, recognition of special needs of adolescents with psychiatric disorders was increasing. Training programs for psychiatrists and special treatment programs for adolescents were developed . In 1971, the first volume of the official publication of Adolescent society, an annual hardcover publication, titled Adolescent Psychiatry, the Annals of the American Society for Adolescent Psychiatry, debuted, under the editorship of Sherman Feinstein. In its early years, Adolescent Psychiatry focused on psychotherapeutic treatment of adolescents, especially from a psychoanalytic point of view. Contributors included leading theorists in the field such as Peter Blos, Erick Erickson, Peter Giovacchini, and D. W. Winnicott. The International Society of Psychiatry was formed in 1984 by a group of French and American adolescent psychiatrists. ISAP, as it was originally known, produced several monographs but did not have a regular publication schedule.
Would you say that adolescent psychiatry has gained prominence as a field of research? Prof. Flaherty:Early on, adolescents were pretty much ignored by both general and child psychiatrists. They were considered difficult and unrewarding to treat or to study. They were often not included in research studies. When I was a trainee in child psychiatry at Johns Hopkins, adolescents were not seen in the child psychiatry clinic but in a special division that was part of the general, or adult, psychiatry department. We did not see any adolescents until our second year of training. I was fortunate during that year to be supervised by Dr. Ghislaine Godenne, head of the adolescent clinic and a founding member of ASAP. That experience convinced me to focus on adolescents in my clinical practice and research, and to become involved in ASAP.
ASAP appealed to both general psychiatrists and child psychiatrists who wanted to learn more about adolescence and treating adolescents. At the time of its founding, what is now the American Academy of Child and Adolescent Psychiatry was known as the American Academy of Child Psychiatry, and had a primary focus on children. Its journal included a few articles related to adolescence. This has changed a lot over the years, and both ASAP and AACAP now include transition age youth in their purview.
What changes have you seen in the field? Prof. Flaherty:Things have changed greatly since I completed my training in 1971. The field of psychiatry is no longer dominated by psychoanalysis. Advances in neurobiology have opened up new ways of understanding development and psychopathology. Recognition of the epigenetic role of trauma, the understanding of schizophrenia as a neurodevelopmental disorder, the biological underpinnings of addiction, and the fluidity of sexual and gender identity, are just a few. The development of advanced statistical techniques in epidemiology has led to a better understanding of risk factors, prevalence, and impact of psychiatric disorders on quality-of-life. We are able to measure changes in brain function in response to psychotherapy. As a result of all these advances we have a better understanding of how biological, psychological and social influences interact. We are in danger, however, of losing sight of the importance of what my colleagues and I have called “being with the patient,” (Harper et al., 2013).
What do you see as the major challenges? Prof. Flaherty:One thing that has not changed is the fact that most adolescents in need of mental health treatment do not get it. This is true even in the richest countries of the world. The field has struggled to find ways to address this problem, to better expand mental health resources and meet unmet needs, especially in the developing world, but also in underserved communities within the developed world. I believe that dissemination of knowledge that is evidence-based and can be useful clinically, is an important contribution to improving care for adolescents. The availability of online communication and open access publication has made possible the rapid dissemination of information throughout professional communities. It has been most gratifying to see increasing contributions to the journal from international colleagues.
We are still unable to diagnose mental illness by brain imaging or other laboratory tests, despite many advances. Our diagnoses remain largely phenomenologically based, and we are criticized for being a soft specialty, as well as over diagnosing individuals. While there is little dispute that psychotic disorders, severe depression, and anxiety disorders are disabling and real medical conditions, there is evidence indicating that some subthreshold conditions are also associated with significant impairment. There is controversy both inside and outside the field regarding where to draw the line between normality and disorder. Diagnostic classifications that are based on conceptualizing disorders as occurring on a spectrum of severity are one answer to this. This issue is particularly important with respect to adolescents, where false positive diagnoses can lead to stigmatization and unnecessary and potentially harmful treatment.
You have had many roles during your professional career. What has given you the greatest satisfaction and why? Prof. Flaherty:Under my leadership, the size and scope of the Division of Child and Adolescent Psychiatry at the University of Maryland in Baltimore expanded significantly. I am particularly proud of the development and expansion of school based mental health services, which came about through a partnership between the Division, the State Department of Mental Health, the Baltimore City Health Department and Baltimore Public Schools. The Division subsequently became the home of the National Center for School Mental Health, a technical assistance and training center with a focus on advancing research, training, policy, and practice in school mental health. Providing mental health services in schools is a way to overcome many of the barriers to treatment – accessibility, affordability and stigma.
Another project that was very satisfying was the State-University Partnership, an NIMH funded program to foster collaborations between State mental health systems and Universities. I was the child and adolescent psychiatrist member of the steering committee for this program, and was able to work with program directors at academic and state institutions around the country to implement what was known as the “Maryland Model.” This model involved incorporating state institutions into the training, research, and service functions of the university, with the goal of improving care in the public sector and broadening the mission of academic institutions. (Flaherty, 1991).
Editors of Academy, Association, and Society journals bring multiple perspectives and expectations to their appointments. Tell us yours. Prof. Flaherty:My perspective is that it is necessary to take into account all aspects of normal adolescent development and psychiatric disorders and treatment. This includes the social environment. While we no longer see everything through a lens of psychoanalytic theory, we should not view psychiatric disorders from a purely biological or purely social perspective either. Given the rapid growth of new knowledge, this is a daunting challenge. Adolescence is a unique developmental period with many risks and dangers but also many opportunities for growth. If we are to help adolescents to realize their potential to be healthy and live meaningful and productive lives, we need to understand their challenges, strengths, and perspectives.
How would you describe the role of Adolescent Psychiatry and the American Society for Adolescent Psychiatry? Prof. Flaherty:As the official journal of ASAP, Adolescent Psychiatry has a responsibility to the membership of ASAP to help it fulfill its role as “a specialized community dedicated to advocacy for adolescent mental health, and the education and development of mental health professionals who serve adolescents and young adults” (https://www.adolescent-psychiatry.org/). I believe it can best do this by publishing a wide range of articles ranging from original research, to reviews and overviews, to case reports and case series. Adolescent Psychiatry is the only journal devoted exclusively to the diagnosis and treatment of psychiatric disorders in adolescents. As I have become aware from my involvement in international organizations such as ISAPP, the issues that we deal with in the US are shared by our colleagues around the world, despite differences in cultural contexts. I am pleased by the fact that our editorial board and contributors are part of a distinguished international community. We have much to teach and to learn from each other.
Lois T. Flaherty Department of Psychiatry Harvard University Medical School Cambridge, MA (USA)