Childhood Vaccine Counseling: Effects on Emotional Health
Gabriel Durben, ND
I recently had a mother of a young child tell me that her experience discussing childhood vaccines was more inflammatory than discussing politics or religion. This sentiment has not been an isolated phenomenon in my practice, and it has led me to further explore the dynamics that exist between the many parties involved in deciding about vaccinations for children. Particularly, I am struck by how – perhaps more than any other clinical issue – the topic of vaccines for children necessarily includes elements that are both intensely personal for each parent/caretaker and inevitably communal, involving the thoughts and opinions of extended family members, friends, neighbors, and acquaintances. Highlighting the challenges inherent within this dynamic, recent polling by C.S. Mott Children’s Hospital revealed that a majority of parents have strong, emotionally-charged opinions about what other parents should be doing regarding vaccinations for their children.1 I suspect that it is often this dynamic which produces such strong emotional responses regarding the topic in general.
Effects of Unresolved Emotional Stress
Recent outbreaks of measles cases in California and elsewhere has led to an outpouring of publications regarding vaccination and infectious disease statistics.2 However, the understanding of how this tumultuous topic influences the emotional health of the family and the child is tenuous at best.3 In light of associated strong, negative emotions, there has also been little focus, within the ongoing conversation, on effective approaches to vaccine counseling.4 While it is easy to get caught up in the debate about the relative effectiveness of vaccinations or the prevalence of adverse reactions to vaccination, the impact of the topic on the emotional health of the family unit is a conversation that we would be wise to invest ourselves in.5 Further, while we may be lacking data for this specific topic, there is much fascinating research on the impact of emotional stress on children, which underlines the importance of considering how the emotionally charged topic of childhood vaccination impacts the family unit beyond the scope of infectious disease.
The research of psychologist John Gottman has consistently highlighted how chronic emotional stress is correlated with negative physical health outcomes.6,7 One particular study that has profound implications for the topic of vaccine counseling – and pediatric medicine, in general – involved the evaluation of emotional stress within households, using standardized questionnaires and measurements of urinary stress hormones.8 The results of his study were striking in the correlation that was revealed between 1) the degree of emotional stress in the parents’ relationship with one another; and 2) the levels of stress hormones in the urine of their children.8 In discussing the results of his research, Gottman has commented on the widespread health implications of chronically elevated stress hormones in children, such as risks for the development of obesity, anxiety disorders, and ADHD. When discussing childhood vaccination, I often counsel parents and caregivers that there is inherent risk associated with any decision regarding vaccination or vaccination avoidance, but there is no ambiguity about the negative health consequences – both for themselves and their children – that are associated with the experience of prolonged and unresolved emotional stress.
Overemphasis on Information Delivery
For each physician, the impediments to understanding and addressing the emotional dynamics of the childhood vaccination conversation are numerous. First, there is relatively little emphasis within medical school training on the development of emotional intelligence within the clinical context.5 Emotional intelligence for the clinician can be summarized as an awareness and insight into the emotional experience(s) of the patient, or family unit, or a facility in assisting the patient or family unit toward a better understanding of their own emotional experience.9 The lack of emphasis on developing emotional intelligence in clinical training is predictably coupled with another challenging impediment: the overemphasis on information delivery within the clinical context.4
The emphasis on information delivery is, in many ways, a noble goal that is inspired by the deep and abiding truth that to be a doctor inevitably involves teaching. Unfortunately, reciting consensus expert opinion or dogmatic philosophical views will rarely, if ever, appropriately address topics that are associated with a strong emotional response from the patient or family unit.10-12 A recently published article in the journal Vaccine provides some interesting insight into this assertion. The study investigated the impact of corrective information on an individual’s intention regarding vaccine choices. The individuals in the study were asked about their understanding of vaccines, as well as the intensity of their emotional state associated with that understanding. Misconceptions about vaccines were identified and participants were given corrective information. After receiving corrective information, the study participants were asked about their intentions regarding vaccination and how their understanding of vaccinations had changed after receiving the corrective information. The study found that individuals who reported higher-intensity emotions associated with their understanding of vaccinations were actually more likely to state that their intentions were to act against the corrective information they received. This phenomenon was not observed with individuals who revealed a lower emotional intensity associated with their understanding of vaccination.13
Cultivating Awareness of Emotional States
All this begs the question: how do clinicians address clinical challenges that are, at their core, rooted in the unique emotional experience of each patient/family unit? The common, and unfortunate, misconception is that solutions to these clinical challenges are impossible to formulate or teach. However, there is evidence to support numerous different models for training clinicians to better understand the emotional experiences of their patients and to cultivate their own emotional intelligence. One approach has been exhaustively researched and documented by psychologist Paul Ekman and his team of scientists. Ekman’s research has focused on the correlation between facial expressions and universal emotional experiences,14 as well as on the capacity for improving an individual’s ability to identify emotional states from observing such facial expressions.15 Their findings have been unambiguous: brief training in recognizing emotional states associated with facial expressions has shown time and again that these skills are not inherent or static, but can be learned through intention and study. They have consistently demonstrated that individuals can improve their ability to identify negative emotions via observation of facial expressions, with training in the physiology and identification of universal emotions.
Another approach to this clinical challenge is proposed by multiple research teams within the mental health field and involves findings from functional MRI (fMRI) studies of the brain and the phenomenon of the Zeigernik effect. Investigation into brain activity with fMRI has revealed the distinct hemispheric action of the brain when experiencing common negative emotions, such as fear or anxiety, compared to when those same negative emotions are articulated in a supportive environment. The experience of fear and anxiety involves a dominant activation of the right hemisphere of the brain, whereas the experience of articulating those emotions in a supportive environment causes an activation of the left hemisphere. Psychiatrist Curt Thompson suggests that the act of articulating the experience of negative emotions in a supportive and safe environment allows for these emotions to be appropriately processed, and decreases the likelihood of perseveration on the negative emotions.16
The Zeigernik effect is a well-articulated psychological phenomenon that further supports this assertion. In brief, the Zeigernik effect can be understood as the propensity of the brain to create vivid and lasting memories from experiences that lack a sense of resolution. Additionally, when an individual experiences a sense of completion for a given event, the memories associated with that event are not as vivid or long-lasting.17
Emotional Intelligence & Vaccine Counseling
The number of parents that I have met in my office that experience a sense of unresolved guilt, anxiety, or fear regarding the health decisions they make for their children has not been trivial. The 2 clinical scenarios below underscore the importance of an emotionally intelligent approach to the topic of vaccine counseling:
- A father of 2 brought in his infant daughter to establish care. His older child had received vaccinations according to the CDC childhood vaccine schedule, and had a diagnosis of autism spectrum disorder. Dad had a good deal of concern that his older child’s condition was impacted by following the conventional vaccination recommendations.
- A pregnant Mom brought in her 10-year-old son for a wellness visit. The child developed pertussis within the first month of life and had to be hospitalized for several weeks due to the illness. Mom was concerned that the child’s recent academic difficulties could be related to hypoxic episodes associated with whooping cough when he was an infant.
In the clinical scenarios above, the practitioner is challenged with the important task of identifying a spectrum of different emotional states that could be associated with the history provided, and assisting the family unit in understanding and articulating their own emotional experience. Let’s consider the various potential emotional states that may be involved with these scenarios:
- The father of 2 may feel quite angry regarding the development of autism in his older child, and may take any conversation regarding statistics on vaccine-preventable illnesses to be an attempt at forceful coercion for medical intervention. OR, he could have a significant amount of skepticism regarding the “vaccines cause autism” theory and a nebulous sense of guilt that he could have prevented the development of the condition in his older child if he had just made different choices early in the child’s life. OR, he could have an entirely different set of emotions regarding his experience.
- The pregnant mom may feel tremendous anxiety regarding the potential of her unborn child to develop whooping cough and want to be reassured that your office forcefully supports or requires conventional vaccine schedules for all patients and has strict quarantine protocols in place in case any patient is suspected of having a highly contagious disease. OR, she may feel quite afraid of excessive medical intervention and is hoping for a clear prioritization of vaccinations for the most likely and deadly vaccine-preventable illnesses. OR, she could have some very different combination of emotions that are only revealed through her tone of voice and nonverbal cues.
It is only through a clinical approach that prioritizes an understanding of the emotional experience of the family unit that adequate insight can be developed. Ultimately, I suggest that this insight is necessary for the clinician in order to appropriately share information that might be new or in contradiction to a parent/caretaker’s understanding of the topic at hand. Further, despite the brief nature of the discussions, I would also argue that successful conversations regarding emotionally charged topics have a positive health impact for the family unit, which extends beyond the scope of vaccination and vaccine-related illnesses. In short, the topic of childhood vaccinations is often associated with intense and diverse emotional experiences for the family unit. For the practitioner, an emotionally intelligent approach to vaccine counseling should include the following considerations:
- What is the intensity of emotions associated with the topic of childhood vaccinations?
- What different emotions are revealed through the history and nonverbal cues from the family?
- How can the family unit be supported in articulating their emotional experience associated with the topic?
- How can information regarding childhood vaccines best be delivered in light of the emotional experiences of the family unit?
Clearly, this is a topic that is in need of further investigation. However, the naturopathic paradigm, with its emphasis on treating the whole person and identifying the root causes of disease, is uniquely positioned to offer meaningful solutions to the diverse clinical challenges that are experienced with childhood vaccine counseling.
Gabriel Durben, ND, is a graduate, former resident, and adjunct faculty member of NCNM. He is currently a clinician at Bellingham Natural Family Medicine, where he primarily sees pediatric patients and families with wide-ranging emotional responses to the difficult questions of life. He facilitates monthly conversations with parents exploring vaccine information and the process of making decisions on emotionally charged topics.
- National Poll on Children’s Health. Parents support daycare policies to get kids up-to-date on vaccines. November 17, 2014. C.S. Mott Children’s Hospital Web site. http://mottnpch.org/reports-surveys/parents-support-daycare-policies-get-kids-date-vaccines. Accessed February 10, 2015.
- National Public Radio. [Search term: vaccination] Available at: http://www.npr.org/templates/search/index.php?searchinput=vaccination. Accessed February 10, 2015.
- Austin H, Campion-Smith C, Thomas S, Ward W. Parents’ difficulties with decisions about childhood immunisation. Community Pract. 2008;81(10):32-35.
- Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 2013;132(6):1037-1046.
- Stoller JK, Taylor CA, Farver CF. Emotional intelligence competencies provide a developmental curriculum for medical training. Med Teach. 2013;35(3):243-247.
- Gottman JM, Declaire J. Raising An Emotionally Intelligent Child: The Heart of Parenting. New York, NY: Simon and Schuster; 1997.
- Katz LF, Gottman JM. Buffering children from marital conflict and dissolution. J Clin Child Psychol. 1997;26(2):157-171.
- Gottman JM, Katz LF. Effects of marital discord on young children’s peer interaction and health. Dev Psychol. 1989;25(3):373-381.
- Rao PR. Emotional intelligence: the Sine Qua Non for a clinical leadership toolbox. J Commun Disord. 2006;39(4):310-319.
- Ozkaya E, Eker HH, Aycan N, Samanci N. Impact of maternal anxiety level on the childhood vaccination coverage. Eur J Pediatr. 2010:169(11):1397-1401.
- Kripke C. Counseling parents about vaccine safety. Am Fam Physician. 2008;78(11):1248.
- Nyhan B, Reifler J, Richey S, Freed G. Effective messages in vaccine promotion: a randomized trial. Pediatrics. 2014;133(4):e835-e842.
- Nyhan B, Reifler J. Does Correcting myths about the flu vaccine work? An experimental evaluation of the effects of corrective information. 2015;33(3):459-464.
- Ekman P, Friesen WV. Constants across cultures in the face and emotion. J Pers Soc Psychol. 1971;17(2):124-129.
- Ekman P, Rolls ET, Perrett DI, Ellis HD. Facial expressions of emotion: an old controversy and new findings. Philos Trans R Soc Lond B Biol Sci. 1992;335(1273):63-69.
- Thompson C. Anatomy of the Soul: Surprising Connections Between Neuroscience and Spiritual Practices That Can Transform Your Life. Carol Stream, IL: Tyndale House Publishers; 2010.
- Gottman J. The Science of Trust: Emotional Attunement for Couples. New York, NY: WW Norton & Company; 2011.