Psychotherapy First: Reflections on Florida's New Guidance for Children's Mental Health Care

Recently, Florida's Department of Health issued guidance urging providers to try psychotherapy before medication for children with mild symptoms, and to evaluate more thoroughly before prescribing at all. Whatever one makes of the broader policy conversation surrounding it, the recommendation itself is one I can applaud. A call for more careful evaluation, and for psychotherapy as a genuine first-line option rather than an afterthought, is consistent with what those of us who treat “treatment-resistant” patients see every day: children who have been medicated for years without ever having had the chance to make sense, in words, of what was happening to them.

In my 2019 paper, "Recovery from Childhood Psychiatric Treatment," I discussed the potential dangers of a reductionist approach to psychiatric struggles, noting evidence that less than half of children on psychiatric medications receive any kind of psychosocial evaluation, let alone psychotherapy. From my perspective as someone who treats patients deemed “treatment-resistant,” many of whom have been medicated since childhood, pharmacotherapy in the absence of meaning-making can introduce real risk of iatrogenic harm. Interestingly, in my experience, the harm is not usually at the level of the medicine itself, which may prove genuinely useful. Rather, the harm comes from the meaning of the medicine—a meaning that can have an outsized impact on children, who are in an especially vulnerable phase of identity development.

Without psychotherapeutic opportunities to explore and metabolize the harder meanings a medication can carry, such as “I’m defective,” “I can’t,” “I am the problem”, those meanings can go unchecked and become woven into a child’s identity during the very process of becoming who they are. As I wrote in that paper, children can be left fundamentally unclear about the difference between the “real me” and the “medicated me,” with real uncertainty about which capacities are their own and which belong to the pill. That confusion tends to run deeper the earlier and longer the medication history, and it runs deeper still when the systems around a child (the school, the family, the treatment setting itself) have already assigned the medication that same meaning, consciously or not. Paradoxically, when medications work well, those meanings may carry more weight for the child and/or their family, and may be more likely to go unquestioned, amplifying potential harms that are carried in meaning.

This is precisely why a more careful, upfront evaluation, and psychotherapy as a genuine first line of defense for mild presentations, matters so much developmentally, and why the integration of psychotherapy for more troubled children may matter even more. A thorough evaluation gives a clinician the chance to understand a child’s difficulties in their psychosocial context rather than defaulting to a purely biomedical explanation before other possibilities have been considered. And psychotherapy, when it is available from the start, gives a child the chance to put language to distress before that distress is handed a diagnosis and a prescription. Even when medication is ultimately the right tool, that groundwork tends to make the difference between a medication that gets used well and one that may be incorporated badly.

None of this is an argument against medicating children who need medication—I made that point explicitly in the 2019 paper, and I’ll make it again here. Children can be harmed just as easily by being denied medication that would help them as by medication that is poorly understood. The point is narrower, and I think less controversial than it sometimes gets treated: when treatment is filtered primarily through a biomedical lens, without room for psychosocial understanding, both diagnosis and treatment suffer. A more nuanced, biopsychosocial “overall diagnosis,” one that leaves room for a child’s symptoms to mean something about their life, and not only their biology, tends to produce more accurate treatment and, I’d argue, better long-term outcomes and affords these medicated children an opportunity to identify and metabolize potentially harmful meanings attached to their medications.

So, I find some hope in guidance like this, regardless of where it originates: that it might return some weight to the psychosocial—the part of “biopsychosocial” that too often survives only as a courtesy word in a treatment plan. If it leads even a fraction of clinicians to ask not only what a child’s brain may need, but what the child makes of what we offer, and who they are becoming as they take it in, that is not a small thing. I’d be glad to hear how others are thinking about it.

David Mintz, MD, is a staff psychiatrist and the Director of Psychiatric Education/Associate Director of Training at the Austen Riggs Center, where he also directs the Elective in Psychodynamic Psychiatry. He is the author of Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient (American Psychiatric Association Publishing, 2022) and of "Recovery from Childhood Psychiatric Treatment," winner of Psychodynamic Psychiatry's 2020 Journal Prize for the most outstanding article of 2018-2019.