The Smallest Possible Intervention
A case for mental health primary care
Your kid is having some sort of mental health struggle. You aren’t totally sure how big a deal it is. On one hand, you know childhood can be rocky, but on the other, your friends’ kids don’t seem to be having this particular issue. And it’s a big enough thing–so unfamiliar and stressful–that you don’t think you can handle it entirely on your own. You talk to the teacher and the pediatrician, and they both agree that you would benefit from some professional support. So you call around to a few clinicians. The options that come back are pretty much always the same two things: a full neuropsych eval or weekly therapy.
I’m not a betting woman, but if I were, I’d wager that you don’t really need either of those. (At least not yet!) Here’s why:
Most mental health struggles in kids are part of typical development. Not pathology. We’ve talked about this before: sleep problems, sibling fights, disorganization at school, picky eating, oppositionality... you name it. These are all unsavory, challenging, normal, and expected parts of childhood. It’s a mistake to medicalize these things and to reach for a clinical intervention every time something feels hard.
First of all, there’s an opportunity cost to everything. A full neuropsych and months of therapy require a lot of time and money, and these resources are often better spent on something else, like playdates and after-school activities.
But beyond the cost, clinical interventions can be stigmatizing. They can shape how a kid sees themselves. Despite our best intentions, kids may implicitly pick up the message that they are broken, something is wrong with them, and they need to be fixed.
So instead of jumping to the full eval or the weekly treatment model, I want a third option. Something closer to mental health primary care.
What I’m envisioning is the smallest possible intervention. Usually this would look like short-term troubleshooting with a licensed clinician who has specific training and can look at the situation from a distance, with some objectivity, and think creatively about how to solve it. I’m talking five sessions or fewer, on an as-needed basis, with solutions-focused work. Check in, see how it’s going, and stop when it’s no longer needed. In terms of how psychology is organized, this would fall under counseling rather than clinical services.
And this kind of work should usually involve the caregivers, not the kid. Kids don’t have full agency over their environments. They can’t enact change the way adults can. If I go see my own therapist and she tells me to adjust something in my life, I’m a fully grown adult, so I can try to do what she says. Kids can’t in the same way, for reasons that are both logistical and developmental. Their lives are run by the adults around them—namely parents and teachers—so those are the people who need to be doing the problem-solving.
Let me give you an example of what this could look like.
Adam was starting kindergarten, and the beginning of the year was rough. He was oppositional at school: arguing with teachers and refusing to participate in classroom activities. The school tried a behavior plan, but it didn’t work. His parents kept getting phone calls from teachers, and nobody seemed to know how to help.
Adam’s mom called me asking if I’d consider seeing Adam for therapy. Instead, I told her to connect me with the teacher and the school psychologist, and together, we set up a meeting. I asked them to show me the behavior plan. It needed real work: the behaviors it meant to address weren’t described objectively, so there was a lot of room for interpretation, which almost certainly meant that implementation was inconsistent and ineffective.
I reworked the plan and sent it back to the school, and suggested a few ways home and school could communicate better. I checked in a couple more times with the parents and the school over the next few weeks, and by Christmas, things had settled.
That’s it. That was the whole intervention. Leaner than a typical therapy model; more consultation than treatment. Plus, we avoided the neuropsych entirely. And it worked.
This is not to say that a full neuropsych and weekly therapy are never appropriate. Of course they are, in some cases. For instance, had Adam’s behavior continued to limit his participation in school, perhaps a neuropsych would have elucidated a cognitive impairment that was getting in the way of his academic success. Maybe a more regular, formal CBT approach would have been necessary to get the level of improvement everyone was hoping for. Who knows?
These just shouldn’t be our first-line treatment options. In the situations where you feel like you need to do something—you don’t feel comfortable with a wait-and-see approach—but a full eval and months of weekly therapy seem like overkill, see if you can find a mental health professional who is able to start with a relatively short-term, light-touch intervention, and up the intensity only when necessary.
There are already well-established models for this sort of approach in other fields. In medicine, we see a primary care doctor before going to a specialist. In education, we try informal interventions before special education services. It’s time the mental health fields caught up and embraced a multi-tiered model of our own.
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I made Eleanor watch this the other night and she thought it was boring.