In inpatient child psychology, we treat children in crisis deemed at imminent risk of harm to themselves or others. I am grateful for the opportunity to try and help — but it is daunting. A study published earlier this year found an overwhelming spike in mental illness-related crises in the past decade. This is particularly true for youth, for whom mental health-related emergency room visits have doubled, with a five-fold increase in the proportion of those visits that are for suicide-related symptoms.
At the start of my inpatient career, six years ago, I embraced what I believed chaos theory identified as the butterfly effect: the notion that even the smallest of interventions can ultimately create a tsunami on the other side of the world. To me, that meant that even in the most complex of cases, every effort made to change how things are going for the child — clarifying that they meet criteria for a major depressive disorder, initiating a new therapy approach, helping them experience safety — counts for something. I embraced the belief that every intervention has potential not just to create positive change and not just in the moment, but also in deeper ways long-term.
Believing in the butterfly effect has offered me the fortitude to face a revolving door of vicarious trauma in a ravaged psychosocial landscape where all too often you start to wonder “what’s the point?” In a safety net hospital setting, the population we serve is frequently under-resourced across multiple social determinants of health. I often fear a youth who is suicidal or engaged in unsafe behaviors simply does not have the financial or familial stability or resources to make recommended changes or adhere to discharge plans.
Never did this feel more true than in the darkest days of Covid when the pandemic created a traumatizing new context of limited mental health and social supports. Those newly or previously suffering with acute mental health issues were suddenly without the lifelines of school and treatment. Providers, teachers, and community members who might have noticed something was wrong were unable to help.
In this isolating and limiting context, significant mental health ailments like anxiety, depression, substance addictions, and psychosis were left to grow unfettered. Fear of going to the emergency departments for any reason, even for someone at risk of suicidality or violence towards others, created another huge barrier to accessing critical acute care.
As we desperately struggled to meet the mental health issues that grew wildly out of control, frontline mental health providers felt helpless to create any change that could feasibly be maintained. I only made it through because I believed that even if what you do might feel insignificant, it is a “butterfly flap,” and that would translate to something significant.
Two years into the pandemic, when I finally found myself relegated to bed with Covid myself for the first time, I spent time perusing the literature on the butterfly effect and was surprised to suddenly learn that I had understood the chaos theory incorrectly.
MIT meteorology professor Edward Lorenz’s work in the 1960s was not about getting leverage, wherein an intervention has implications for a specified predictable or desired end. Lorenz’s point was almost precisely the opposite — that it is virtually impossible to predict the magnitude or direction of a small intervention.
Lorenz had hoped to prove that technology used to direct weapons and launch satellites could be used scientifically to yield accurate weather forecasts. It seemed logical that the right equations made up of accurate data on a set of measurable factors — like temperature, pressure, and wind velocity — should render adequate predictions.
But he found something else: Something as small as a butterfly, which makes a tiny change in the state of its environment, can create unpredictable, even very large, changes in a later state, yes — but that effect really ultimately depends upon the initial conditions of that environment. In other words, while it is true that a butterfly flap can create a tsunami somewhere on the other side of the world, that flap had to happen at exactly the right space and time where the initial conditions of the environment created potential for that outcome.
I was shocked. I had so heavily relied on my simplistic, albeit flawed notion of the butterfly effect — it provided a salve to the chronic exhaustion of grappling with endless uncertainty about making any difference and it buoyed me to be brave at the most hopeless moments. The loss made me recognize how badly I needed a framework to latch onto and to ground myself in this work. Something to help me make sense of trying to treat chronic, acute mental illness that has no certain outcomes ahead and for which stability will chronically be undermined by external havoc.
Suicidal and homicidal ideation are more prevalent than ever for youth. We will see the ramifications of the added traumas of the pandemic well into the future. As the demand for mental health treatment for youth has climbed sharply, we have a shortage of mental health professionals including psychologists, psychiatrists, and psychiatric nurses, and a chronic dearth of inpatient treatment beds. Providers are leaving the field in droves as they find it a challenging place to sustain hope and effort. Those of us who remain feel keenly aware of how the burden of need grows while the resources we rely upon diminish. In this weighty context, I was scared to lose the framework that allowed me to maintain belief in my work.
I sat and struggled with my new discoveries at length, carefully considering what it really means if we do not know where a butterfly flap may take us. I had been focusing on the potential for prompting a tsunami as the compelling piece of the framework. The butterfly flap had seemed the small and potentially insignificant part.
Then it dawned on me: Without that critical flap, never mind a tsunami — there was no chance for change of any kind.
The key goal of an inpatient admission is to change the trajectory of problematic functioning in order to improve safety. Actively identifying and disrupting the part of the youth’s life which is in a pattern of disrepair (i.e., using psychotropics to change brain chemistry, clarifying the function of self-injurious urges) requires daring and bold clinical work. Creating disruptive change for our patients is about helping them to be brave and try to change something that is not working, often while in crises and despite fear of what might happen next. We ask them to consider using a self-soothing skill when they want to self-injure, or to try a new kind of therapy.
We are in many ways doing the same, choosing to press for sometimes quite stressful and daunting interventions to create disruptive change even if we are not able to control or leverage against some of the uncertainty about where it will take us. We have to believe deeply in the crucial influence of that disruption, no matter what follows. I realized that the work had never been about counting on the tsunami. It had been about holding firm the belief that the butterfly flap might or might not create a tsunami, but it was essential either way.
Further, the emphasis on initial conditions in chaos theory reminded me that understanding and formulating what brought the patient to our doors is vital. These are the factors that most heavily determine the youth’s trajectory. If a youth’s mental health is the system under consideration, the initial conditions are the intertwining of biological, psychological, and social factors that make up their starting point. Chaos theory underscores how critical it is to gain as much knowledge as possible about these conditions. In other words, an inpatient hospitalization may be just the right space and time for some disruptive butterfly flaps in the form of thoughtfully selected interventions.
When I returned to work after these revelations, my new understanding of the butterfly effect changed how I approached my patients.
I’m still hopeful for the butterfly flaps that will build tsunamis. But I now sit with more assured awe and respect for the butterfly flaps that fill the air with a different kind of motion. I also believe more deeply than ever that whether or not our efforts launch tsunamis, mental health providers create impactful disruption in this great, big overwhelming world.
Sharmila Bandyopadhyay Mehta is the clinical director of the Child and Adolescent Psychiatry Inpatient Service for Cambridge Health Alliance/Harvard Medical School. She has expertise in treating youth with acute and chronic psychological and behavioral health difficulties, and evaluating youth with potential for violence.