Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Wednesday, May 8, 2013

DSM, NIMH on mental illness: both miss relational, historical context of being human

It seems that the National Institute of Mental Health (NIMH) may have dealt a death blow to the recently published Diagnostic and Statistical Manual of Mental Disorders (DSM 5) when the organization declared they would no longer fund research based on the DSM system of diagnosis. The views of NIMH director Thomas Insel were referenced in the recent New York Times article on the subject.
His goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.
I am no fan of the DSM system, which reduces complex experience to lists of symptoms; focusing on the "what" rather than the "why."  However, the NIMH model has limits as well. There seems to be a wish to study mental illness in the same way we study cancer or diabetes. While I certainly have great respect for the complexity of the pancreas, or the process of malignant transformation of cells, trying to understand the brain/mind in an analogous way seems to be an unnecessary and even undesirable reduction of  human experience.

What is missing from both paradigms is recognition of the relational and historical context of being human. Fortunately there seems to be awareness that neither paradigm is complete. The Times article goes on to say:
Dr. Insel is one of a growing number of scientists who think that the field needs an entirely new paradigm for understanding mental disorders, though neither he nor anyone else knows exactly what it will look like.
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.

Unfortunately when people hear the term infant mental health, they imagine babies lying on the couch.  In reality, the field offers a way of understanding all of human experience, well beyond infancy.  I recently taught a course on infant mental health to clinicians at the Austen Riggs Center, a hospital that offers intensive inpatient treatment for severely disturbed patients. None of them are infants- the youngest are in their late teens and most are well into adulthood.  My students found the insights from infant mental health very valuable for understanding and treating their patients.

The Center for Disease Control (CDC) Adverse Childhood Experience (ACES) study provides extensive evidence of the long-term effects of early exposure to a range of negative experience, including parental mental illness, divorce, abuse, and neglect, on mental health. The more severe the mental illness, the earlier in life disruptions to development probably occurred. Knowledge of infant mental health (that spans age 0-5) offers a textured understanding of this early experience.

Looking at an individual brain and/or genes, or listing the behavioral symptoms of an individual person, out of relational and historical context, how can one possibly understand the complexity of human experience? This complexity is represented by such things growing up in the home of a Holocaust survivor, a depressed parent,  in the setting of ongoing war trauma, with a physically and emotionally abusive parent, or some combination of all of these. A recent article on the blog ACES Too High,  "What motivated the Boston bombing suspects?" offers a fascinating look at the Tsarnaev brothers from an ACES perspective. The use of the word"motivation" in the title represents a curiosity about the meaning of behavior that is representative of an infant mental health perspective.

The ongoing research coming from the discipline of infant mental health offers growing knowledge about effective, primarily preventive, interventions. Not only do we need this research to continue, but we also need to grow a workforce trained in infant mental health to offer these interventions on a large scale. When the NIMH looks for a new paradigm towards which to direct funding, I hope they will look to the paradigm of infant mental health.

2 comments:

  1. After reading Dr. Insel's blog post, I had to double-check NIMH's mission statement, to see if they are mandated to only focus on the biological basis of mental illness.

    From their About page:"NIMH envisions a world in which mental illnesses are prevented and cured...The mission of NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure...

    I'm glad that "prevention" is in there, because I think that gets to the heart of what infant mental health is all about. However, the use of the word "cure" bugs the heck out of me; are they really that out of touch with reality over at NIMH? Or perhaps they have to use "cure" to secure Congressional funding. In any case it seems reflective of the dysfunctional society and times in which we live.

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  2. This is exactly right, Claudia. Well said.

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