A paradigm is a way of thinking about things. For the past 60 or so years, our thinking about mental health and illness has been dominated by what can be referred to as the “DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm.” What this looks like in everyday practice is that when a child is referred to my behavioral pediatrics practice for anxiety, the questions that parents, referring doctors, and teachers ask is, “Does he have anxiety disorder?” followed by “How to we manage his behavior?” and “Does he need medication?”
The DSM paradigm has been useful as a way of organizing our thinking. But it is important to recognize that these “disorders” of anxiety, depression, ADHD are simply lists of symptoms that tend to go together. They do not correspond to any known biological processes in the way that, for example, diabetes is a result of lack of insulin.
When the DSM system was first created, we did not have the powerful health insurance and pharmaceutical industries that we have today. Because of the existence of these entities, we are currently in a position of being forced into a very narrow view of mental health and illness.
The DSM system is a black-and-white paradigm, with only the possibility of “normal” or “disordered.” According to the DSM paradigm, if the answer to the first question about my anxious patient is “no,” and there is no diagnosis, then there is no insurance coverage, and no help. But clearly such a family is struggling.
We need a paradigm shift: a fundamental change in approach and underlying assumptions. A new paradigm is needed that gives room for the complexity that we have learned from the abundance of research at the interface of developmental psychology, neuroscience and epigenetics.
The child noted above may have a strong family history of anxiety traits. He may have a strong genetic vulnerability for anxiety. However, if a parent who shares these traits was slapped across the face for her “difficult behavior” when she was a child, she may become so overwhelmed with stress in the face of her child’s challenges that she is unable to help him to manage his anxiety. Marital conflict, perhaps exacerbated by the stress of a child who is struggling, can further add to the complexity. The environment in which this child grows and develops will determine the way in which his genetic vulnerability is expressed.
As I described in a previous post, the growing discipline of Infant Mental Health offers just such a paradigm. This discipline is characterized by four key components. First and foremost, it is relational, recognizing that humans (and that includes their genes and brains) develop in the context of caregiving relationships. Second, it is multidisciplinary. Experts in infant mental health offer different perspectives. They come from many fields, including, among many others, developmental psychology, pediatrics, nursing, and occupational therapy. Third, it encompasses research, clinical work and public policy. The field looks at mental health within the context of culture and society. And last, it is reflective, looking at the meaning of behavior, not simply the behavior itself. The ability to attribute motivations and intentions to behavior is uniquely human, and research has shown that this capacity is closely linked with mental health.
This paradigm gives us a way to organize our thinking about the problems of the family I describe above. It offers a path to treatment, namely to support the efforts of the child’s parents to recognize the complex meaning of his behavior. Once parents feel heard and understood, and have the opportunity to make sense of their child’s behavior, they will be better able to help him manage his anxiety. They might involve him in physical activities or creative activities that help him to feel calm in his body. They might get help for their own relationship. They might work together with the child’s teachers to strategize about how to support him in the school setting.
A number of years ago, thanks to my first book, Keeping Your Child in Mind, I had the honor of being invited to give the Paul A. Dewald lecture at the St Louis Psychoanalytic Institute. My book is about the idea that rather than jump to “what to do” about a child’s behavior, it is important to simply “be” with that child; to think about that child. As I prepared the talk I came to recognize that the same holds true for our whole system of mental health care. Before we can plan “what to do” to apply the wealth of research I refer to above, we must first recognize that we need to “think” differently. We need to embrace a paradigm shift. An important first step is to name it as such.