Adapted from Searching for Normal: A New Approach to Understanding Mental Health, Distress and Neurodiversity. (Penguin Random House Canada/Signal, 2025.)

February 1992. I’m in the consulting-room side of a one-way mirror divide. Opposite us in the room are four people: thirteen-year-old Sofia, her older sister Julieta, and their mother and father. The parents speak with a strong Spanish accent. The girls’ mother has an anxious look on her face. She has one hand on Sofia’s knee. Sofia looks away perhaps in embarrassment or disgust (at herself or her mother?), Julieta is looking at Sofia with a sharpness that suggests annoyance, occasionally rolling her eyes when Sofia or their mother speaks. Their father, physically separate (his chair being out of touching distance with the rest of his family), only answers questions if specifically asked. He seems somewhat peripheral to the charged relational dynamic in the room. They are here because Sofia has recently taken an overdose of paracetamol.

I’m feeling overwhelmed. I have recently started my first placement in a child and adolescent psychiatry service. This is the first time I am in front of the one-way mirror. Interviewing a whole family where intense emotions are swirling is new to me.

I’m learning that in child psychiatry the “identified patient” (in this case Sofia) is not the only, or even the main, focus of therapeutic efforts. Sofia exists within a relational network, and working with this network may be more impactful than trying to treat something in her mind. At the time, I don’t recall any questions of diagnosis. We were more interested in the face-value descriptions of what led to a referral. There were “behaviour problems,” “eating issues,” “self-harm,” “suicidal feelings,” “overdoses,” and occasionally “psychotic” presentations. We didn’t categorize anyone as having ADHD, or autism, or childhood depression. This was how I was taught child psychiatry.

In adult psychiatry, I concluded that you spend most of your time as a glorified pharmacist. All I could see from adult psychiatry practice was a conveyer belt of changing or adding medications until patients had cycled through the limited number of drugs a psychiatrist can prescribe. The patients you see in clinic become numbers in a system, living a chronic relapsing course, spending year after year in psychiatric services. The gift of child psychiatry to the rest of psychiatry, and indeed to health care in general, is twofold.

• First is development: Development broadly helps us appreciate that life is in constant motion, that change is the one predictable aspect of living. When dealing with young people you know their bodies change, so will interests, relationships, emotional depth, what they view as significant and important, their ambitions, sleep patterns, social and political beliefs, the music they like, their sexuality, and so on. The only thing I can predict with certainty when I see a young person is that they will change. However, none of us know in what way they will change. There’s something marvelous about that.
• The second gift is understanding that life exists in contexts: Most of the important decisions that affect children’s lives are not made by them but by various people in caring relationships to them. Our life contexts simultaneously provide possibilities and limitations. There are material contexts, social contexts, historical contexts, cultural contexts, and relational contexts, and our understanding of what is happening in our lives will be influenced by all of these. Each context contributes to the nature of the meaning-making frameworks through which we scaffold our experience and interpret the significance of all that happens to us.

I consider myself to be a traditional child psychiatrist. Respecting the twin pillars of development and context has allowed me to view what we consider as mental health problems through the lens of the ordinary and extraordinary, rather than normal and abnormal. This means thinking systemically and developmentally about the dilemmas that people face at certain points in their lives. All we can do is generate various subjective hypotheses about the situation of a person/family, and the nature of that hypothesis will carry implications for how we then intervene. We cannot know the truth about their experiences.

Little did I know, when I first stepped into the world of child psychiatry three decades ago, how far and deep the tentacles of diagnostic mental health ideology would reach. Diagnostic ideology’s pathologizing, labelling, and medicating is strangling my adopted profession. There has never been a generation of young people so colonised by mental health propaganda.

These days practice in child and adolescent mental health has been expunged of the curiosity and openness of a developmental and contextual backdrop, in favour of “treatment pathways.” In the treatment pathway model, you get a diagnosis, which then informs you about the correct treatment. This individualized model has facilitated the growth of certain therapies, particularly cognitive behavioral therapy (CBT), on the one hand, and medication use on the other. The idea of seeing young people, like Sofia, in the context of their family and community, is now relegated to a side show, where the young person might be referred to a “family therapy clinic.” This is a model that sees the patient as the location of the problem when things don’t improve after receiving what is considered the correct treatment for their diagnosis. When this happens you become at risk of accumulating new diagnoses, being labelled as “treatment-resistant,” and having medications added to whatever has already been prescribed.

Now people cling to their diagnoses. They have become woven into their identities. The medical establishment has long been selling the story that each problem has a cause (a diagnosis) and a technical solution, whether pharmaceutical or psychotherapeutic. In a strange contortion of logic, it’s not unusual to hear “I thought it was just me, but now I know it was my ADHD,” with ADHD then simultaneously occupying a role as an identity and the function of “something that’s not me.”

It seems a lifetime since the days I first encountered and found sanity in child and adolescent mental health. I can hardly picture those times any more.

Sami Timimi is a child and adolescent psychiatrist and psychotherapist and author of Searching for Normal: A New Approach to Understanding Mental Health, Distress and Neurodiversity.