Dennis was trying to sandwich a conversation with us between meetings with hyperanxious parents of newly admitted kids and preparations for the upcoming two days of parent-staff seminars. He seemed rushed and slightly edgy. Bob and I began the conversation with a recitation of our lingering concerns: Was Dennis confident that Will no longer harbored thoughts of suicide? Was the change we were seeing in Will’s mood real? What about the medication? Should he continue with the drugs and/or therapy? Did he think Will would regain his footing and make the transition back home with relative ease?
The four parents crowded around the desk in Dennis’s tiny office on the lower level of the lodge, looking out on a cluster of snow-topped evergreens. Dennis shifted in his office chair uncomfortably. Over the past ten months, he had spent more time with Will than any of us had, and yet, even to Dennis, Will presented a conundrum he couldn’t solve. He confided that Will represented one of the most stubborn cases of adolescent depression he had ever treated.
“So are you saying he’s still at risk?” I probed warily.
“I don’t think so. But you know, I see him in group and individually every day for weeks and I’ll be driving home from campus, from what I think was a particularly good session with Will, and I’ll suddenly stop and it hits me—he hasn’t said anything different from the day he came in here. I have no idea what he’s thinking. And that troubles me.”
The neurochemical roots of Will’s depression were inordinately hard to reach with medication; it had taken roughly nine months to see a noticeable turnaround in his depression. Likewise, Will posed a challenge for any good therapist: he never revealed much in their sessions and was loath to share his true feelings with any one individual or in a group.
We could all agree that on the surface Will was a terrific kid: polite, easygoing, bright, and popular at Montana Academy; Dennis and others told us so. But on a deeper level, Will remained an enigma to his therapists, who hoped they could shed some light on the root causes of his depression. He had fooled us before. Would he fool us again? Will was done with the program and there were still big chunks of his persona locked in a trick box of his own making. If it was troubling to Dennis, it was gut wrenching for us.
“I believe Will’s gotten as much as he can get out of Montana Academy,” Dennis allowed. He conceded he was pleased the pharmacological cocktail was finally showing good results. But with a degree of candor you are rarely afforded by a physician these days, Dennis admitted he was reluctant to make confident predictions about Will’s future, free from depression. It was too soon in his mind to feel assured that Will had conquered this demon.
Dennis was as compassionate and as skilled an adolescent psychiatrist as they come. He cared deeply about kids and understood adolescent boys better than anyone we had come across. But I have learned that physicians abhor broken patients they cannot mend. Given the nature of mental illness, it’s much more difficult to pronounce a mind “healed” than a reconstructed kneecap. Dennis could not help this patient anymore; he had put his all into it, but as therapeutic outcomes go, he did not herald it a hundred percent success.
We had been down this avenue with Will and therapy before, back in January when Dr. Salerian first released Will from PIW, and again after his suicide attempt in March. Were Will’s troubles so profound that he would go to any length to conceal them? Was his depression idiopathic, defying conventional diagnosis and treatment? Or was Will an exemplar of a subset of kids who suffer from major depression who stand apart from the rest because their illness hides behind outward manifestations of “normal”—the kid who’s anxious to please, a perfectionist who conforms to the norm and tries to live up to everyone’s expectations.
I don’t have the answer. Perhaps I never will. But the doctors’ inability to chart a clear prognosis for Will underscores just how hard it is to diagnose and treat adolescent depression. So little is known about this illness; we’ve barely scratched the surface since investigations into the nature of adolescent depression began in the twentieth century. I am confident, however, that medical breakthroughs are occurring at a frenetic pace, that what we know now about adolescent depression will be augmented exponentially in the coming decade, and that science will tease out all of the actors involved in depression—stress, genes, environment, diet, exercise—and add these variables to what we already know about the disease. And we can hope that by 2010 the pharmacology will be light-years beyond where it is now.
In the meantime, as a parent, I conclude where I began: you invest as much time and energy as possible mustering the information you need to serve as your child’s best advocate, and then you trust in your own judgment. It is a crapshoot. And, as I have said before, the risks of making the wrong calculation are immeasurable. But until science offers more hope by way of empirically based options, a lot of treatment regimens are subject to trial and error, and the burden falls to us, the parents, for better or for worse, to seek out the best remedies for our troubled children. Do not give up.
Our final meeting with Dennis was over in half an hour. I sensed that this was not the closure Dennis had hoped for; it certainly did not play out the way we had hoped it would. We thought we would be tying up all the loose ends of this chapter in Will’s life. We had asked for assurances that Will was no longer at risk for another suicide attempt; Dennis just confirmed what we already knew: there are no such guarantees. He postulated that the next decade of Will’s life would be crucial to assessing whether Will’s depression was idiosyncratic, perhaps just a fluke of neurological and/or biological mishaps triggered by the onset of puberty ransacking his adolescence. Or, it was possible, and, unfortunately, a statistical possibility, that his depression was chronic and that he would suffer another episode sometime in his life, perhaps with a frequency or severity mimicking my own history with the illness.
As we were getting up to leave the meeting, Dennis offered a little sliver of comfort. He proposed we use age thirty as a benchmark.
“Look, by the time Will turns thirty, he will have learned to manage the illness. Either we won’t see his depression return in his twenties, or he will be able to handle it if it does.” By age thirty Will may be home free. In the meantime, we have no choice but to watch him and love him. In the end, isn’t that all a parent can do?
The world at large now recognizes depression as a serious illness, even though different cultures elect vastly different approaches to treatment. It is possible that Eastern traditions of healing, which emphasize the physiology of the mind-body connection, will meld with contemporary Western practice to provide new approaches; it is also possible that the global reach of pharmacology in the next decade will narrow rather than expand the exploration of remedies outside the boundaries of conventional medicine, which would be unfortunate.
In the spring of 2004, I called Dennis Malinak and Montana Academy director Dr. John McKinnon to try to get a sense of where they and the program stood with regard to the debate over antidepressant medication for adolescents. After all, a therapeutic boarding school is the perfect laboratory for close observation of the effects of medication on adolescent behavior, given the microscopic monitoring and rigorous therapeutic regime. Dennis was encouraged by the results he was getting from the pharmacological interventions for his teen patients.
“Gail, I wish we could do brain scans of all the kids entering the Montana Academy program and then again when they leave.” Not only was he seeing dramatic improvements in the kids with mood disorders, but he went so far as to voice hope that antidepressants may play a role in inoculating the brain from future bouts of mental illness for young people treated at this particularly vulnerable time in their brains’ development. In fact, current research is under way at the National Institute of Mental Health that may soon prove the brain’s ability to override the circuitry involved in depression by introducing medication at the earliest sign of illness.
“I think this possibility holds out great promise for kids like Will,” Dennis
offered.
“So you don’t necessarily think it’s a given that he’ll suffer from another bout of depression? You don’t think we need to hold our breath for the next several years?” I asked.
“No, I’m optimistic that some of these kids won’t see a recurrence of depression in their lifetimes.”
Let’s hope he’s right.
Will returned to Washington in early March—a full year after his suicide attempt. He moved back into his second-story bedroom facing the street, its north-facing windows bumping up against the out-of-control blooming pear tree putting on a repeat of last year’s luxuriant snow-white show. All his things were there, exactly where he had left them eleven months earlier: same khaki pants and muted plaid shirts hanging in the closet, same eleventh-grade American history and chemistry notebooks lining the bookcase, same Simpsons’ memorabilia on top of the dresser.
To look at him in March 2002, a kid, so contained, so gentle, so seemingly unperturbed—who would guess, in this everyday setting that broadcast: “I’m just a regular kid, living this regular life,” who would guess what had transpired? Who would guess that one night barely a year before he was hell-bent on self-destruction, that he had been dragged down to the lowest point in human emotion and that he had taken us, his family, with him into uncharted depths of despair.
Will had done the hard work, adhered to the structured discipline of a therapeutic program. In those first few days back home, he earnestly exuded a sense of balance and stability—and wellness—and I, just as earnestly, wanted to believe what I was seeing. He also had youth and resilience going for him. I, on the other hand, remained bereft of the self-confidence I took for granted when, five or ten years ago, I thought I knew everything about my children.
After he had been home for a few weeks, I came to the realization that Will would bounce back from this chapter in his young life quicker and with more agility than I would. And for that, I should be grateful; he’s a child, and children heal faster. Did I really expect to subvert the natural law of child rearing? To be a parent is to know suffering in a boundless dimension. My scored and tested parent heart would mend slowly. It is mending still.
In the first few weeks after Will’s return to Washington, Jack, Will, and I tried, with better than average results, to establish a routine. The program at Montana Academy, with its 24/7 structure and intense supervision, was relegated to his past but left its mark—initially Will was at odds with his new freedom. Although he was never much of a risk taker (let’s discount the suicide attempt), he now approached the world with more caution than one would expect of an eighteen-year-old boy. But then, we were cautious, too. He stuck to the relatively early curfew without complaint and I held on to and administered his medications, doling the requisite dosages out morning and evening. I bought him a cell phone and insisted he let us know his every movement. He was compliant and courteous—almost unnaturally so.
In late March, Will and all of his cousins flew to Georgetown, Texas, for the weekend. The kids flew from as far away as Australia, New York, and California for what would be the grandchildren’s final visit with my mother, who died a few weeks later on April 14. My mother was in fine spirits and was tickled to see them. They sat by her bedside, looked through old photographs of themselves and their parents, and made forays into town to sample coconut cream pie at the local diner my mother raved about. In many ways, it was a very uplifting reunion for Will, reuniting him with the extended family that he loved and who loved him.
Will flirted with and halfheartedly pursued a couple of full-time jobs and simultaneously enrolled with a temporary employment agency, which kept him working at entry-level office jobs two or three days a week, beginning in early April. He wore his khaki pants and ironed his oxford cloth shirts for job interviews. He hung out with his old friends, in particular Vic and Henry and his stepbrother, John. In his spare time, he read prodigiously, a habit left over from Montana Academy. And he wrote in his journal.
Our initial attempts to interest him in at least investigating colleges for the fall semester (though it was too late in the season to take the process seriously) failed, and after a month or two, I simply stopped raising the topic. He maintained that he was not ready to accept the discipline attending college full-time would require; I accepted his decision with resignation and hoped that he would find the idea of college appealing somewhere down the road.
As the weather got warmer and the school year for Will’s friends and peers drew to a close, his buddies were following through with plans formulated over the course of the past two years. Some kids were bound for college in the fall, others were simply glad to be graduating from high school, getting jobs, and moving out of the house.
Again, I suffered minor pangs of regret that Will’s launch onto the stage of adulthood had departed so radically from paths open to many of his friends. He did not have a “plan,” and his lack of a plan, or his inability to articulate and follow through with a design for the future, troubled me. It troubled all of us.
As spring turned into summer, he languished, contentedly and seemingly without purpose, as he continued to search for full-time work and tackled a variety of part-time jobs. Was I putting too much emphasis on his plans for the future? He didn’t seem worried, and when I would initiate a conversation on the topic, he would try to reassure me that he had things well in hand.
“No, Mom, everything’s fine; I’m getting there; I’m working on…” Or, “I’m waiting to hear back from…” The object of the exercise varied from week to week.
From time to time, he entertained an earlier aspiration to pursue an apprenticeship with a union; he even brought home application forms for several job training programs. The union apprenticeship appealed to him because he figured he could draw a “decent” wage—decent enough in his mind to get a place on his own and maybe even buy a car; and if he eventually decided to pursue a degree in something like electrical engineering, the union would send him to school. Aha! A romantic blue-collar dream, but hard to fathom as a match for a kid absorbed in writing and literature, not to mention girls. There weren’t likely to be many young women pursuing union apprenticeships in the electrical workers union. And, knowing Will, it was hard to imagine him being at work by 6:30 AM, lunchbox in hand, spending eight to ten hours at a job site and wrapping it all up with a couple of brews with the guys in the evening. I judged him to be too laconic and introspective to fit into the lifestyle. But I was willing to be proven wrong.
Will continued to see his therapist, Dr. Vaune Ainsworth, and faithfully took his medication, but I still worried that he had too much time on his hands. Was he drifting? Was this just a stage of recovery? I didn’t know whether to cut him slack—after all, I knew better than most how difficult it is to bounce back after an episode of major depression—or to press him harder to move along. We were bound up in a tight little mother-son dance, trying to get in synch with the music for a few more months.
By late spring, Will had a new girlfriend, Sarah, a high school senior at a local Catholic girls’ school, whom he met at McDonald’s one night after bowling with his friends. She was a sweet, lovely young person, bound for college to study classical piano. They shared an easy affection.
Through Sarah, Will and Will’s friend Vic found jobs as summer camp counselors at a nearby Quaker school—uncomplicated teenage summer jobs. Will worked with the littlest campers, who clung to him with the reverence accorded a minor celebrity. He got a kick out of his kids and entertained us in the evening with stories about his day, about a child who habitually wiped his nose on Will’s sleeve or another who had an interesting way with words. The job was just what he needed. He had found a carefree niche to occupy his time for eight weeks; he earned a regular paycheck and hung out with his friends. And it got us off his back short-term. Still, no evidence he was coming closer to a “plan” for the future, but he was certainly enjoying this moment.
We reviewed the home contract in terms of bracketing his ree
ntry and transition home. The contract was a signpost for the first six months. Presumably, if all was well, we would either abandon or renegotiate the terms, effectively prescribing whatever degree of independence we felt was his due. The end date was fast approaching: August 22, six months from the day he departed Montana Academy. He was now eighteen and a half years old.
“Okay, Will, it’s showtime,” I urged silently. “Time to get moving.” But I could not forecast where he was headed. His girlfriend and some of his friends were in the throes of packing for college, severing ties and moving on. Will didn’t seem perturbed by their imminent departures, nor did their moves seem to spur him on to a path of his own.
If a child is lucky enough to get into college and find the means to pay for it, almost everyone, young people and their parents, is well served by the experience. The college experience offers a young person, from roughly age eighteen to twenty-two, some tangential benefits, not all of them academic. Considering the prominent role neurobiology plays in teen behavior, I think college is an ideal place to park a young person’s underdeveloped prefrontal cortex for four years. At college, kids can experiment and explore new ways of thinking and behaving away from home and parental unease. They can act out, do completely ridiculous things, engage in risky behaviors, and, as long as they remain within the confines of “acceptable” or “legal” (the terms of which are defined by their peers, the authorities, or both), you can reasonably expect a young adult to emerge at the end of the process with measurably more maturity, judgment, and aptitude for life than the person who entered.
We would be a better country if there were an established place in society for young people who are still floating, who aren’t ready to move as quickly as some others right out of high school. We desperately need more opportunities that offer experience in community service programs or training in the trades. Certainly the military is an option for many, but we are just now beginning to appreciate fully that during wartime, a portion of the young people who serve will return with debilitating and long-term mental health issues that are often dismissed or inadequately addressed. Society pays in the long run for the millions of kids who have limited opportunities to extend the maturation process beyond high school.
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