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 developmental science 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.

Saturday, October 3, 2015

Can Mental Health Care be Freed From the Medical Model of Disease?

I recently ran in to a colleague, an experienced psychotherapist, who marveled at my ability to "get out from under the medical model of disease." I have been fortunate to work with colleagues in the growing field of infant mental health who come from a range of disciplines. They bring model of strength and resilience, rather than a disease model, to treatment of emotional and behavioral problems of early childhood. 

Younger psychiatrists trained in the age of biological psychiatry have grown up in a professional family with a language of disorders. This language has likely shaped the way they think. It is embedded in their brains in a way similar to the language we grow up with in our homes. As such it may not be easy to change.  But the abundance of evidence at the interface of developmental psychology, neuroscience and genetics suggests that the path to healing lies in listening for the meaning of behavior, not in simply naming disorders and eliminating symptoms. The biological model of disease reifies the DSM (Diagnostic and Statistical Manual of Mental Disorders) diagnoses, when in fact they simply are descriptions of behaviors, or "symptoms," that tend to go together. 

This point was brought home for me when I taught a class on early childhood mental health to a group of child psychiatry fellows at a well-respected Boston teaching hospital. I was presenting the work of child psychiatrist Bruce Perry.  His neurosequential model of therapeutics (NMT,) that guides treatment based on an understanding of brain development, grew out of his frustration treating children with trauma histories according to the medical model. He recognized this approach was failing.   After presenting his alternative model in detail, I described a case of a 7-year-old boy with a complex history of early developmental trauma who was impulsive and getting in to dangerous situations.  I turned to the group of fellows and asked how they might treat this family. The first response was, "I would see if he met diagnostic criteria for depression and consider an SSRI." 

In another example,  I had a conversation with a young psychiatrist about our work with mothers who are struggling in the postpartum period. We agreed that there is a broad range of factors contributing to these struggles. There is the cultural context, with many mothers experiencing social isolation and unrealistic expectations of rapid return to pre-pregnancy functioning. The transition to parenthood under normal circumstances involves massive biological and psychological shifts. Relationships between partners are dramatically altered, and when both partners struggle alone, the sense of social isolation is magnified. And then there is the baby, a new person with unique qualities that may make this transition more challenging, for whom parents are now completely responsible.  I suggested that we think of the term "postpartum depression (PPD)" as an umbrella term that encompasses all of these factors. I wondered if the biological model of disease, that placed the problem squarely in the mother, might be limiting our approach. She replied, "but any good therapist would look at all these things when treating PPD." 

This way of thinking is exactly the problem I was trying to point out. When we speak of postpartum depression as a complication of pregnancy "just like diabetes" we reify the "disorder."  We need to listen for the full complexity of a new mother's experience before we label her with a psychiatric disorder. If, for example, the baby was premature and has difficulty with feeding, we can find meaning in the mother's struggles that lead us to treat the mother and baby together. Or if the father is feeling depressed and abandoned, the treatment might be a father-baby group. Or a mother who is in a new neighborhood with little social support and a spouse who works long hours might need a mother-baby group and an opportunity to go to the gym. I wonder if we really needed to label  a mother with a "disease" in order to engage this kind of support. 

A third example of this reification comes from a child psychiatrist in a blog post about the new DSM 5 diagnosis "Avoidant/Restrictive Food Intake disorder."  He wondered if this represented a "real problem" or over-pathologizing a normal behavior. There is a third option not mentioned anywhere in his article. Eating is a relationship-based behavior with often complex meaning. In my forthcoming book I have numerous cases of picky eaters whose behavior was a communication of distress related not only to sensory issues but also to troubled family dynamics that were only uncovered with space and time for listening. 

In our current system of health care, diagnostic categories are necessary for insurance to cover treatment. In all of these circumstances I describe above, treatment is definitely needed. It is important not to fall in to the trap that if it is not a "disorder," it is "normal" and therefore families don't need help. I use the generic "adjustment reaction" to avoid this trap and still work within the system. When it comes to working with young children and families, this "disease" vs. "normal" is an inaccurate and potentially dangerous dichotomy.

I am hopeful that the explosion of knowledge of the developmental science of early childhood is making its way in to mainstream mental health care. This is in part due to the Adverse Childhood Experience study that shows the long-term impact on both physical and mental health of early childhood experiences.  I hope it will be possible for all mental health professionals to learn a new language, not of diagnosing disease and eliminating symptoms, but of listening with the aim of promoting growth, healing, and resilience.



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