2019-06-11

When people find out I am a child psychiatrist I inevitably get asked about why so many kids are struggling with anxiety and depression. There are lots of theories---social media, increased pressures at school, biological and environmental factors. The list is long. But the truth is experts don’t know the exact cause. There is a lot that goes into why somebody struggles, and I think sometimes doctors, social workers and parents spend too much time trying to figure that out at the expense of the child.

So how can you help someone with mental health issues, if you don’t know what’s causing the problem? Focus on what they need.

If your child gets sick, you don’t spend a lot of time hunting down the classmate that passed along the cold, you focus on what will make your child get better.

A new approach to anxiety and depression that’s actually old.

In the 1950s psychologist Abraham Maslow developed a hierarchy of needs that forms the basis of most modern psychology. This model assumes that individuals are innately motivated to grow and thrive and will self-propel in this process of becoming if basic needs are met. Maslow called this process “self-actualization” in his conceptualization. This means that traditional efforts to motivate others through rewards and consequences – “carrots and sticks” – are at best narrowly useful, at worst harmful, and caution is warranted.

Think of a batter who has stepped up to the plate in the last inning of a baseball game, with bases loaded, two strikes and a state championship on the line. On top of all that, if the player strikes out, the other players are going to throw rocks at him. No doubt the player is extremely motivated to hit the ball but there is no reward or consequence that will assure he hits the ball.

Even the “laziest” teen will often tell me in my office that they really do want to be successful in school, have a better relationship with his or her parents, or do something productive in life, they usually just don’t know how, often feel powerless (controlled by others), or are too afraid to try (and fail) due to unsuccessful past efforts. Often the oppositionality or avoidance that parents see is a discouraged teen’s attempt to “save face” or maintain some sense of pseudo-power to compensate for a terrifying sense that they are just not making it.

A much better approach then is to start by assuming that people want to be good and be successful. However, in order to be able to self-actualize (grow into our best selves), we all have basic needs that need to be cared for, or else our motivation will be focused on preserving those more basic needs rather than more fully thriving. These needs include those for (1) safety, (2) connections, and (3) confidence/competence.

Safety, connection and confidence creates resilience.

The need for safety often confuses people because we aren’t talking about physical safety. It means that you are safe to talk. Safe to be yourself. Safe to fail. Safe to feel.

Parents will often ask me why their child’s medication isn’t making them happy. The purpose of medication is to help a child function not take away their ability to feel.

When a child is overwhelmed with anger, sadness, or anxiety a parent’s first reaction is usually to try and fix the situation. Acknowledging that feelings are okay is an important lesson to teach your kids.

As for connection, parents do all kinds of big things to create memorable moments with their kids but sometimes they don’t recognize that it’s the simple moments that create the most important connections. A smile, a shared joke or just sitting down on the floor and playing with your child is what forms the bond.

The confidence piece of the hierarchy triangle is all about growth. Our kids (and even some adults) think that their life is all about performance. Teens will say things like, “I’m really stressed out. I’m in ninth grade now and ninth grade counts.”

They feel like they’ve already become who they are going to become and from now on everything they do is going to be measured and there’s no more opportunity to grow.

We as adults need to maintain perspective so that when a teenager is going through a difficult time, we aren’t the ones freaking out.

Often the best way to help a child feel confident is simply to express confidence in them. Don’t try to solve their problems. Instead, express belief in their ability to figure things out on their own.

We're in this together.

A second implication of the model is that a person’s basic needs are supported by others, meaning the burden is on us – natural caring systems – and not on the individual. Humans are social creatures and have very likely required social groups throughout history to obtain food, experience safety, feel connected and so forth. In other words, simply telling a child to “get out and find friends so you will feel more connected,” or “work harder so you feel more confident” is missing the point. We do not “teach resiliency skills,” but build internalized resilience through the daily care and attending to these emotional needs. This is neither about having children meet their own needs, nor can parents or teachers over-control and over-determine what growth or self-actualization will actually look like. It admittedly requires faith in one another. I like to think of approaching the relationship the way you would a ride together on a roller coaster: I will ride with you and be next to you no matter what (safety), will love the closeness, shared laughs and screams (connection), and know that you will be braver and feel more accomplished for the risk (confidence).

There is no shortage of confusion when it comes to mental health. We argue about causes, definitions and treatments. We organize, advocate, publish, and publicize around what seems to be a growing problem; and yet most people I meet with just don’t know what to think or what to do. We can feel hope and confidence when we sharpen our focus to what a person actually needs. My wish would be that each of us would take a moment each day to pause and ask ourselves: “what am I doing today to help the children in my life feel safe, connected and confident?”