Lauren brought her son Lucas to my practice in the fall of his freshman year. They had just moved to Manhattan from Brooklyn, and he was starting high school with a whole new group of kids he had never met before. According to Lauren, Lucas seemed socially disconnected. He wasn’t participating in activities the way he used to. He was hesitant to speak in class, and he refused to join the school’s soccer team. Halloween came and went without any plans, which especially stung because it fell on a Saturday. Lauren wanted to know whether Lucas was depressed. She believed he needed therapy.
Families like this come through my door all the time. The child is struggling, but I’m not convinced there’s anything pathological going on. The family needs guidance from a mental health professional—usually reassurance, and maybe targeted strategies—but it’s unclear whether they meet criteria for a diagnosis or need ongoing therapy. And if you’ve been hanging around here for a while, you know that I’ve been advocating for a model I call mental health primary care, in which people like Lauren consult with a mental health professional about everyday struggles without committing to intensive clinical services. I am of the mind that interventions should be proportional to the severity and nature of the difficulty, and therefore, our goals as mental health professionals should be to provide the smallest intervention likely to be effective and to prevent rather than treat most psychopathology.
In the model I have in mind, much like a primary care physician, a psychologist or social worker could conduct an initial assessment focused on understanding the problem, its context, severity, and functional impact. In many cases, they could provide things like psychoeducation, parent coaching, and environmental modifications. They could monitor progress while those informal interventions are implemented, and provide referrals for comprehensive evaluation or intensive treatment if they ultimately don’t work.
To be clear: I’m not suggesting that we minimize or ignore difficulties, but we should respond appropriately to them. When Lauren came to my office, I didn’t think Lucas needed a diagnosis of depression. A reasonable clinician might have disagreed and interpreted Lucas’s presentation as real psychopathology; I just didn’t. Instead, I thought he’d benefit from some help settling into a new school and a new social world: check-ins to monitor his mood, coaching for Lauren on how to nudge him toward low-stakes social opportunities, and a conversation with the school about ways to help him connect with classmates. I suggested low-touch (i.e., time-limited, inexpensive) interventions rather than interpreting and treating the problem as a full-fledged mood or adjustment disorder. I was able to take the psychological problem seriously without treating it as pathology.
The need for such a service seems obvious, yet few providers offer it.
What makes this gap especially surprising is that psychology already has an entire professional specialty historically devoted to this sort of thing: counseling psychology. While clinical psychology focuses on diagnosing and treating psychopathology, counseling psychology helps people navigate ordinary life challenges and function more effectively. Counseling psychology’s sheer existence suggests the field has long recognized that people can benefit from psychological expertise even when they do not have a mental illness. Yet over time, psychological support has become synonymous with clinical interventions, i.e., treatments for diagnosed psychopathology.
Though clinical and counseling psychology are technically separate subfields with distinct traditions and training emphases, the historical distinction between them has blurred. In New York State, clinical and counseling psychologists hold the same professional license. There is no required credential that distinguishes the two. Both clinical and counseling psychologists must pass the same licensing examination, which tests knowledge across a range of psychological domains, and licensed psychologists must possess at least foundational knowledge relevant to both clinical and counseling approaches. And in practice there is more overlap than separation. Counseling psychologists can assess, diagnose, and treat psychopathology, while clinical psychologists can provide counseling, consultation, and strengths-based interventions.
So the issue isn’t that we lack professionals who have the knowledge and expertise to provide mental health primary care. We have plenty. Instead, it’s that our mental health system emphasizes diagnosis and intensive treatment over preventive care and low-touch interventions.
The emphasis on clinical care is due, at least in part, to mental health care being incorporated into broader medical and physical health service delivery systems. Affordable mental health care is extremely difficult to access. Insurance coverage is, in most cases, limited to medically necessary treatment for diagnosable conditions, and people who don’t meet diagnostic criteria have few affordable options for accessing psychological support. Preventive guidance, parent consultation, and brief problem-solving services can be difficult to get reimbursed. Thus, there are incentives for patients and providers to conceptualize difficulties as disorders, even when a less pathologizing approach might be more appropriate. The system offers few options between doing nothing and initiating formal treatment for some sort of mental illness.
So clearly we need more sustainable reimbursement structures. Mental health primary care cannot happen if services aren’t financially viable. Insurance companies should reimburse brief consultation, preventive services, and targeted psychological guidance when appropriate, even without a diagnostic code that signifies illness. Otherwise, mental health primary care will simply become another private-pay service accessible only to affluent families.
At the same time, I’m encouraging our field to reclaim the counseling tradition. Counseling psychology provides an established foundation for supporting people through normal, expected difficulties in a way that aligns naturally with mental health primary care. Licensed psychologists are well positioned to develop and lead these services, and I encourage fellow clinicians to make counseling-oriented care a more visible part of their practice.
I’m thinking about hosting small-group Zoom chats (6–8 parents) to talk through some of the big themes in Actually, You’re Fine: raising kids, when to intervene, and when to step back. Let me know if you would be interested!
And this week I’ll leave you with the Rogers and Marks!
Yes! Yes! Yes! To all of this. This is the element of practice that is essentially navigating what it means to be a human. Not every hard thing is psychopathology. And if we can allow the human experience to include challenges without catastrophizing we can learn to cope well. And if we keep an eye on things, through models of primary mental health care like this, we can really get ahead of and intervene when the pathological stuff does happen.
The Department of Defense does a great job with this. For years, my office was in the pediatrics department of a military hospital or in a family primary care clinic. Medical providers could consult with me if they had a family in their office who needed the types of short-term, focused sessions you describe, and I still had the opportunity to see more traditional therapy patients as well.