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 say, 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 etc, 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 in to 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, there is no insurance coverage, and so no help. But clearly such a family is struggling.
We need a paradigm shift, defined as 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 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 field of infant mental health offers such a paradigm. It is relational, developmental and founded in the basic principle that behavior has meaning. It 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.
Thanks to my book, Keeping Your Child in Mind, I had the honor of being invited to give the Paul A. Dewald lecture this week in St Louis. My book is about the idea that rather than jump "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 move beyond the DSM paradigm and embrace a new paradigm; to facilitate a paradigm shift. An important first step is to name it as such.
paradigm etiketine sahip kayıtlar gösteriliyor. Tüm kayıtları göster
paradigm etiketine sahip kayıtlar gösteriliyor. Tüm kayıtları göster
28 Ocak 2016 Perşembe
27 Ocak 2016 Çarşamba
Towards a new (or return to an old) paradigm of finding meaning
I am fortunate that my father is my greatest fan, although, perhaps because his original language was German, it has taken me years of patient listening and translation to recognize this fact. Recently, after receiving a biography of Charles Darwin for his 89th birthday, he has taken to comparing me to Darwin.
I would certainly be more modest, recognizing that the ideas I write about draw on the work of great thinkers and researchers, together with my own clinical experience. One of these great minds is Sigmund Freud. His discovery of the unconscious, his greatest contribution, is so much a part of the way we think and behave that is difficult to appreciate the revolutionary nature of this idea. Even before he used the term unconscious, in his work as a neurologist, his original discovery was that symptoms have meaning.
Freud did not write very much about development under age three, perhaps because there was only so much he could do. However we do know that when he was a toddler his younger brother died. I wonder how much this early experience, and his mother's concurrent grief over the loss of her child, influenced the development of Freud's theories, though perhaps in a way that he himself was not conscious of.
Fortunately the next wave of researchers, including such great minds as John Bowlby, Peter Fonagy and Ed Tronick, and many others in the growing discipline of infant mental health, have focused on early development, showing that not only does behavior have meaning, but also how that meaning is co-created in relationships.
Here is an example. I have written on this blog about my growing recognition of the significance of sensory processing challenges in development. While such a trait may originate in the child, it immediately takes on meaning within relationships. A newborn that is not cuddly and does not like to be held may evoke feelings of shame and even depression in a mother. A father who himself had sensory processing challenges but was physically abused because of his difficulties may be overwhelmed with anxiety in the face of his child's similar problems. The child's behavior takes on meaning in the context of the parent-child relationship. When a child is a newborn, it may be relatively easy to identify the relational nature of these problems. But when a child is older, there are layers of complexities, such as learning difficulties and concurrent self esteem issues that may accompany sensory processing challenges, or marital conflict that may occur in the face of a child who is struggling. These complexities are usually out of a parent's awareness, or, returning to Freud's term, unconscious.
As a society we have come far from this idea of looking for the meaning of behavior. Instead we treat only the symptom. Thus a child who has sensory processing challenges, unless he is working with an occupational therapist trained in infant mental health, may be treated by brushing, or listening to tapes designed to "re-program" his brain. Many parents have told me that they are actively discouraged from participating in the therapy. Yet if parent and child are separated in this way, the meaning of a symptom within the context of relationships is never discovered.
In mental health care, this shift away from the search for meaning is due at least in part to the birth of "biological psychiatry" and the hope that complex emotional struggles have a simple chemical explanation that can be solved with a drug.
On the list serve of the American Psychoanalytic Association there is currently an active discussion about the issue of CPT codes. In order for a service to be covered by insurance, a clinician must provide both a diagnostic code and a code for the type of service. An underlying problem is that our system of diagnosis, largely based on the DSM (Diagnostic and Statistical Manual) is organized by symptoms, not by meaning. Clinicians who are used to helping people to discover meaning are restricted by a system that reduces these complex meanings to a number that corresponds to a list of behaviors. It is a deeply entrenched issue related to the whole structure of the health insurance industry and of our health care system. It is further complicated by the rise of electronic medical records and concurrent implications for confidentiality. Helping people to discover meaning that may be unconscious often involves intimate and private conversations.
This brings me full circle to my father's flattering comparison. It is indeed true that I am motivated not only to help the individual children and families I work with, but also to promote a paradigm shift in how we as a society understand human development, and, in turn, support newborns, young children and families.
Though my father is a magazine publisher, he is not a big fan of social media. He told me that Darwin kept his discoveries to himself, partly in fear of upsetting the mainstream thinking, until he had it all written down in the Origin of Species. My father suggested that I concentrate my efforts on producing my own analogous work.
He has a point. However, I choose to embrace the age of social media, and so aim to move our thinking one blog post at a time (although another book will also be forthcoming.)
I would certainly be more modest, recognizing that the ideas I write about draw on the work of great thinkers and researchers, together with my own clinical experience. One of these great minds is Sigmund Freud. His discovery of the unconscious, his greatest contribution, is so much a part of the way we think and behave that is difficult to appreciate the revolutionary nature of this idea. Even before he used the term unconscious, in his work as a neurologist, his original discovery was that symptoms have meaning.
Freud did not write very much about development under age three, perhaps because there was only so much he could do. However we do know that when he was a toddler his younger brother died. I wonder how much this early experience, and his mother's concurrent grief over the loss of her child, influenced the development of Freud's theories, though perhaps in a way that he himself was not conscious of.
Fortunately the next wave of researchers, including such great minds as John Bowlby, Peter Fonagy and Ed Tronick, and many others in the growing discipline of infant mental health, have focused on early development, showing that not only does behavior have meaning, but also how that meaning is co-created in relationships.
Here is an example. I have written on this blog about my growing recognition of the significance of sensory processing challenges in development. While such a trait may originate in the child, it immediately takes on meaning within relationships. A newborn that is not cuddly and does not like to be held may evoke feelings of shame and even depression in a mother. A father who himself had sensory processing challenges but was physically abused because of his difficulties may be overwhelmed with anxiety in the face of his child's similar problems. The child's behavior takes on meaning in the context of the parent-child relationship. When a child is a newborn, it may be relatively easy to identify the relational nature of these problems. But when a child is older, there are layers of complexities, such as learning difficulties and concurrent self esteem issues that may accompany sensory processing challenges, or marital conflict that may occur in the face of a child who is struggling. These complexities are usually out of a parent's awareness, or, returning to Freud's term, unconscious.
As a society we have come far from this idea of looking for the meaning of behavior. Instead we treat only the symptom. Thus a child who has sensory processing challenges, unless he is working with an occupational therapist trained in infant mental health, may be treated by brushing, or listening to tapes designed to "re-program" his brain. Many parents have told me that they are actively discouraged from participating in the therapy. Yet if parent and child are separated in this way, the meaning of a symptom within the context of relationships is never discovered.
In mental health care, this shift away from the search for meaning is due at least in part to the birth of "biological psychiatry" and the hope that complex emotional struggles have a simple chemical explanation that can be solved with a drug.
On the list serve of the American Psychoanalytic Association there is currently an active discussion about the issue of CPT codes. In order for a service to be covered by insurance, a clinician must provide both a diagnostic code and a code for the type of service. An underlying problem is that our system of diagnosis, largely based on the DSM (Diagnostic and Statistical Manual) is organized by symptoms, not by meaning. Clinicians who are used to helping people to discover meaning are restricted by a system that reduces these complex meanings to a number that corresponds to a list of behaviors. It is a deeply entrenched issue related to the whole structure of the health insurance industry and of our health care system. It is further complicated by the rise of electronic medical records and concurrent implications for confidentiality. Helping people to discover meaning that may be unconscious often involves intimate and private conversations.
This brings me full circle to my father's flattering comparison. It is indeed true that I am motivated not only to help the individual children and families I work with, but also to promote a paradigm shift in how we as a society understand human development, and, in turn, support newborns, young children and families.
Though my father is a magazine publisher, he is not a big fan of social media. He told me that Darwin kept his discoveries to himself, partly in fear of upsetting the mainstream thinking, until he had it all written down in the Origin of Species. My father suggested that I concentrate my efforts on producing my own analogous work.
He has a point. However, I choose to embrace the age of social media, and so aim to move our thinking one blog post at a time (although another book will also be forthcoming.)
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