Posted on

Why Psychodynamic Therapy is Harmful for Eating Disorder Patients

1.) The approach is based upon theory rather than empirical data.

Decades ago, when psychologists and psychiatrists first began treating eating disorders, psychodynamic therapy was the only tool they had. Science has come a long way since then. While there is still so much about the illness that we don’t understand, we have learned a great deal in the past decade about the etiology of eating disorders and how to treat them more effectively. Why use theory-based practice when we have evidence-based practice?

2.) It confuses symptoms with causes.

For example, one psychodynamic theory posits that girls develop anorexia nervosa due to their fear of growing up and their desire to remain child-like. In reality, the ammenorhea and boyishly-thin bodies of anorexic girls are symptoms of the illness.

3.) Insight and motivation are over-emphasized, especially early in treatment.

Insight and motivation are crucial to sustaining wellness later in the recovery process. But patients with anorexia nervosa suffer from anosognosia, a brain-based inability to recognize that they are ill. The problem with emphasizing insight and motivation early in treatment is the presumption that the patient must “choose” to get well and that, if she does not make that “choice,” no one else can make it for her. Precious weeks, months, even years are wasted trying to form an alliance, cultivate motivation, and develop insight.

4.) It presumes that the patient’s family dynamics are at least partially to blame for the eating disorder, and that correcting the family dysfunction will help the patient recover.

There is no reliable scientific evidence to support these theories. Families of eating disorder patients do typically present for treatment with high levels of conflict and tension. The conflicted parent-child relationship, however, is most likely the result of the eating disorder rather than the cause. Having a child with any serious illness creates enormous strain on even the healthiest, most functional families.

5.) It presumes that there is a “deeper meaning” in symptoms which are the result of malnourishment and/or faulty brain chemistry.

A great deal of time and money is wasted attempting to discern this deeper meaning. Meanwhile, the patient’s brain and body are failing, placing him or her at risk of permanent medical and psychiatric problems. I advise patients and families: Don’t waste time on “why.” The reality is that we don’t know exactly what causes anorexia nervosa or bulimia nervosa.

We still do not know the cause of many types of cancer, but we begin aggressive cancer treatment immediately upon diagnosis because the longer it goes untreated, the more grim the prognosis becomes. We can remove a tumor or give chemotherapy without knowing how the tumor originated. The same principles apply with eating disorders – the patient’s nutrition and weight must be normalized immediately, and dangerous behaviors must be stopped right away. The patient will benefit from these interventions, both physically and mentally – even if the “reason” for the eating disorder is unknown.

6.). Too much attention is paid to early experiences, often at the expense of solving problems in the here and now.

Psychodynamic theory presumes that psychiatric disorders stem from early childhood experiences. In reality, childhood experiences are generally irrelevant to the patient’s eating disorder. Even in instances in which early experiences are relevant to the current illness, there is no evidence that an ill patient can overcome her eating disorder “exploring” or “processing” such experiences.

7.) Too much value is placed on the relationship between therapist and patient.

While I completely agree that the therapeutic relationship is very important to the healing process (and there is solid research supporting this), I believe that this relationship must take a backseat to treating the eating disorder aggressively. This means that in order to be optimally effective, the therapist must listen to the patient’s basic needs rather than her expressed wishes (translation: the ED’s wishes), consistently nurturing her relationships with family members when she (translation: the ED) wants them to leave her the f*** alone, and setting firm limits on her ED behavior immediately rather than waiting for her to develop the motivation and insight to do so herself. In my experience, this often means that the patient (translation: the ED) will hate me at the beginning of treatment, then gradually grow to trust, admire, and respect me as treatment progresses and her brain returns to healthy functioning. Most patients eventually express gratitude for that early toughness and understanding of what had to be done, recognizing that they wouldn’t have been able to recover without it.

8.) It undermines the relationship between the patient and his or her parents.

Psychodynamic therapy involves deep exploration of childhood experiences and family relationships in attempt to uncover the seeds of the patient’s current mental conflict. The typical result of this type of therapy is that the patient begins to distrust and resent her parents for making her ill, and the parents back off even further out of fear of making problems worse. This results in further exacerbation of existing family conflict and the creation of new problems, once the patient “realizes” how pathological her family really is.

We now know, through research on family-based treatment, that empowering parents to help their children overcome eating disorders is actually the most effective way to help them recover. I believe that nurturing positive relationships between the patient and her family members is essential for full recovery and ongoing relapse prevention, as family members are usually the first to notice signs of struggle, and the first ones to intervene.

9.) It is extremely difficult to undo the damage done by psychodynamic treatment.

A substantial amount of the trauma that patients and families endure is not the result of the eating disorder itself, but rather the result of bad treatment and protracted illness. Often, patients and their families come to me for family-based treatment after months or years of traditional therapy which has not been effective. Even a newly-diagnosed patient will struggle with re-feeding, but having a history of traditional treatment makes the process much more tumultuous. It is extremely difficult for the patient to accept meal support from their parents when they have been conditioned to believe that separation/individuation issues are at the root of their illness, or that they have developed their eating disorder as a way to survive in a dysfunctional family, or that they will recover when they choose. Further, parents struggle enormously to become empowered to act on their child’s behalf when they have been blamed for causing the illness, either overtly or subtly, by their child’s previous clinicians.

10.) It does not bode well for relapse prevention.

Unfortunately, eating disorders have a very high rate of relapse, in part because the underlying biological vulnerability stays with the patient for life. In order to maintain full recovery, it is extremely important for the patient to maintain his or her optimally healthy body weight, practice excellent self-care, manage stress adaptively, and eat a complete, well-balanced diet. The beliefs that one’s eating disorder resulted from internal conflict, or that “it’s not about the food,” are not terribly conducive to these protective measures.

As science has progressed and newer, more effective treatments have been developed, there has been a backlash from the “old school.” Those who remain entrenched in outdated, unproven psychodynamic theories will defend their beliefs like a lioness defends her cubs because – let’s face it – these theories are their babies. They have built careers on these ideas; written books about them; conceptualized their own recovery through these lenses. But that does not make these theories correct, or evidence-based, or useful, or effective in treatment.

Let’s welcome a new generation of clinicians who use evidence-based treatment that strengthens family relationships, treats deadly symptoms rather than hypothesized causes, and promotes full and lasting recovery for all patients. Let’s welcome a new generation of patients and families who are not blamed for the illness, but are empowered to pursue aggressive, effective treatment upon initial diagnosis. Let’s welcome treatment that actually works and refuse to support treatment that doesn’t.

Posted on

Time after Time

“I don’t have time.”

This is an excuse I hear all too often. When I recommend a health-promoting behavior to a patient, such as sleeping at least 8 hours per night, meditating, spending quality time with family and friends, or exercising regularly, some people respond reflexively by stating that they don’t have time. Others will give a more wistful response, such as: “Oh, I would love to, I know it’s good for me, but I just don’t have the time.” There are patients who cancel their therapy appointments because they “don’t have time” to attend, and those who fail to complete their therapy homework citing lack of time. While I sympathize with the feeling, I don’t buy this excuse.

Here’s the thing: time is the great equalizer. We each have different amounts of money, different abilities, different families, and different life circumstances, but we all have the same amount of time. Every single person on this earth is given 24 hours in each day, 7 days in each week, and 52 weeks in each year. What we do with that time is up to us. Believe it or not, you have quite a bit of control over how you spend your time.

When someone claims that they don’t have time to do X, what they really mean is that X is not important enough to make time for it. When you reframe the statement this way, it sounds much more pointed and critical, yet it is startlingly accurate:

“My mental health is not important enough to me to attend weekly therapy sessions.”

“I don’t care enough about my wellbeing to make the time to exercise regularly.”

“I’m choosing not to bring my daughter to therapy every week because attending volleyball practice is more important than her recovery.”

“My family just isn’t significant enough for me to take time out of my day to be with them.”

“I’m not coming to therapy tomorrow because it’s finals week, and my grades are much more important than my recovery.”

It is all a matter of priorities. We define ourselves and create our destiny, in part, by how we choose to spend our time. People spend substantial chunks of time each day twittering, texting, facebooking, watching television, and surfing the internet. There is nothing inherently wrong with any of these activities. When used appropriately, they can be entertaining and life-enhancing. But when a college student tells me she has no time to sleep or exercise, and yet she spends two hours a day on facebook and goes out drinking with friends three nights a week, this says something about her values and priorities. When a parent claims that she “doesn’t have time” to transport her child to weekly therapy appointments, but clearly has the time to transport said child to soccer practice, voice lessons, youth group, and SAT prep classes, this too says something about how much the parent values her child’s mental health.

Most people would take time off from work or school to see their family doctor if they were sick. Most parents wouldn’t think twice about making time for their child to have chemotherapy, dialysis, surgery, or even orthodontist visits. Yet somehow, treatment for mental illness is not viewed with the same urgency. This is a huge mistake.

Individuals living with mental illness have more physical health problems than those who are mentally healthy. Depression costs society billions of dollars each year in lost productivity, not to mention suicide. Eating disorders often become chronic, disabling conditions and have mortality rates close to 20%. Schizophrenia and addiction often lead to homelessness. So why do we continue to view mental health treatment as optional or extracurricular? Why does our behavior suggest that mental health treatment is less important than work, school, sports, or facebook?

The impact of mental illness on individuals, families, and society is enormous, but the benefits of good mental health are immense and immeasurable. Improved mental health means increased productivity, reduced stress, more rewarding relationships, improved physical wellbeing, and overall satisfaction with life.

Achieving and sustaining good mental health is not merely a matter of attending therapy appointments, just as achieving physical health requires far more than visits to your doctor. Successful treatment for mental illness involves significant time, energy, and effort outside the therapist’s office. Many types of mental illness come with a life-long predisposition, so sufferers must be ever mindful of controlling symptoms and preventing relapse, even after complete recovery. Developing good self-care habits, completing therapy homework assignments, and creating a lifestyle conducive to overall wellbeing are all part of a holistic approach to mental wellness.

Think carefully about how you spend your time. Ask yourself if the way you spend your time reflects your true values and priorities. If mental health is a priority for you, don’t just say it – LIVE it – and the benefits of good mental health will be yours to enjoy.

Posted on

A False Dichotomy

One of the things that bothers me most about my field is the false dichotomy between biology and psychology. On the one hand, there are psychiatrists who over-diagnose and overmedicate without taking the time to get to know patients and truly understand their symptoms. They spend very little time with patients and try to solve everything with a pill, rather than providing psychotherapy or referring patients to a psychotherapist. These psychiatrists do not take into account the role of environmental stressors, lifestyle (nutrition, sleep, substance use), and learned patterns of thinking that can be successfully treated without medication.

On the other hand, there are therapists who over-pathologize and overanalyze. These therapists are married to unscientific, unsupported psychodynamic theories about the etiology of psychological problems which tend to attribute symptoms to supposed family dysfunction and internal conflicts. These therapists fail to take into account the powerful role of genetics and neurobiology in contributing to the patient’s symptoms. They ignore or discount the recent scientific advances in our field, and they do not employ empirically-supported treatments which have been demonstrated to be effective. They rely instead on their opinions and “clinical judgment.”

Neither side of this dichotomy serves its patients well, as both sides fail to appreciate the true complexity of the human experience. One side places all eggs in one very small proverbial basket (a pill), effectively abnegating the patient of any responsibility for behavioral, psychological, or environmental change. The other side places an unfair amount of blame on the patient and / or her family, searching for root causes that may not exist, traumas that may never have occurred, or dysfunction in normal thoughts and behaviors. Consequently, it is implied, if not blatantly asserted, that biologically-driven thoughts and behaviors are freely chosen and can be un-chosen just as freely with enough insight into said root causes, traumas, and dysfunction.

I am often disappointed by those mental health professionals who have so little scientific understanding of the interaction between genes and environment, between biology and psychology, between experience and neurodevelopment. They seem to forget that the mind is an abstraction of the brain, and the brain is part of the body. Their thinking is so dichotomous – disorder X was caused by either genes OR environment; treatment must be medication OR psychotherapy; it’s a neurobiological illness OR it is caused by environmental factors. They don’t seem to understand that, with mental illness, it’s rarely a question of “nature or nurture.” Rather, it is nature AND nurture, both of which come in many forms. Biology, psychology, and environment are constantly interacting, with each of these components profoundly impacting the other two.

I would like to see all mental health professionals develop a full understanding of and appreciation for biopsychosocial models of mental illness and evidence-based treatments. It is my hope that psychologists, psychiatrists, and mental health professionals from all disciplines will begin taking a more well-rounded approach to treating psychiatric disorders and helping people achieve mental health.

Posted on

What a Difference a Year Makes

A funny thing happened at work this spring. It hit me one day that my patients with serious or chronic mental illnesses were doing a whole lot better. Many of them had recovered completely. Others still had a few symptoms which were relatively minor, manageable, and well-controlled. What was responsible for this dramatic and rather sudden improvement? Was it the gorgeous springtime weather? No, this is Miami – the weather here is gorgeous year round. Was it something I was doing differently? No, because I have been using the same evidence-based treatments all along.

And then it hit me. I opened my private practice in March 2009. A number of patients have come and gone since then – mostly those with mild or moderate issues who did very well with just a few months of CBT and were ready to end their treatment. Then there are those with more severe mental illnesses whom I’ve been seeing since last spring – those with anorexia, bulimia, severe depression, and personality disorders. Those longer-term patients are doing exceptionally well now because a full year has passed since they began treatment.

So many ingredients go into a successful recovery from mental illness. My recipe typically includes some combination of the following: psycho-education for patient and family, weekly therapy using evidence-based practice, full and consistent nutrition, restoration of physical health and weight, family support, a stable and low-stress environment, acquisition of healthy coping skills, plenty of sleep and exercise, psychotropic medication, clarification of core values, creating a full and meaningful life, and time.

That last ingredient – time – is often forgotten but absolutely essential for recovery. It takes time for parents to learn how to manage their child’s mental illness. It takes time for a patient and her family to grasp fully what it means to have major depression or borderline personality disorder or anorexia nervosa. It takes time for a patient’s brain to heal, for her neural pathways to re-wire. It takes time for the therapeutic relationship to flourish. It takes time to learn and master new skills and implement them in daily life. It takes time to heal broken relationships and build a life worth living. It takes time for the dedication, persistence, and heroic efforts of the patient and family to translate into psychological health and stability.

We live in a fast-paced world of high-speed internet and instant coffee, of fast food and quicktrim and rapid refills. Patience is a virtue so few of us possess. As burgeoning technology has made so many things quicker and easier, we have become far less tolerant of things that require us to wait and persevere. It can be humbling and frustrating to realize that some things still require considerable time and effort.

Most things that are truly worthwhile in life take time and effort. Earning an advanced degree, mastering a foreign language, writing a novel, learning a new sport or musical instrument. Starting a business, building a strong friendship, nurturing a romantic relationship, creating a family. None of these things happen quickly. Those who struggle with mental illness have an added challenge of expending considerable time and effort to do the things most people take for granted – getting out of bed in the morning, eating a meal, leaving the house without having a panic attack, tolerating emotional pain without self-destructive behavior. These people face the additional burden of shame and stigma, expensive and time-consuming treatment which is typically not covered by their insurance, family and friends who don’t understand, and the absence of that proverbial quick fix. Treatment for mental illness is SO HARD and it takes SO LONG, but it is definitely worth it!

My time in private practice – 15 months now – has been the most rewarding experience of my life so far. I have seen victims become survivors; suicidal students develop a thirst for life; skeletal teens blossom into self-confident young women. Those desperate parents of sullen kids who once curled up in a fetal position on my couch became joyful and optimistic as their child’s bubbly personality reemerged. All of these miracles took time.

There are new patients now – those who cry in despair and lash out in anger, those who would rather not exist than endure another day enslaved to their own minds. There are the terrified, exhausted parents who wonder when this hell will ever end. These brave souls keep me humble, keep me challenged, and most importantly, keep me going. I have faith and hope that by next spring, they will be strong and stable and full of life, that I can say goodbye and trust that they will never have to see me again.

If you are battling a mental illness in yourself or in your loved one, remember this: time heals. Be a tortoise, not a hare. As Winston Churchill famously said, “When you are going through hell, keep going.”

Posted on

How to Help Your Depressed Teenager: Tips for Parents

If your child is depressed, it is important to act now. Untreated depression causes tremendous suffering and can lead to serious medical and emotional problems, including suicide. Adolescents with untreated depression have difficulty learning and making and keeping friends. They are also more likely to abuse drugs and engage in self-injury. You must intervene now in order to help your teenager blossom into the wonderful person she was meant to be.

1. Educate yourself on depression in adolescents.

Learn the signs and symptoms of depression and know how to differentiate between normal sadness or “teen angst” and clinical depression. All teenagers are moody and irritable at times, and sadness is a natural and healthy response to a loss or disappointment. Depression is a serious but treatable mental illness which affects between 2-5% of adolescents at any point in time.

Depression involves a pervasively sad or irritable mood that lasts at least two weeks, but usually several months or more, and causes a noticeable change in functioning. Depressed adolescents also experience physiological symptoms such as changes in appetite and weight, lack of energy, insomnia or hypersomnia, and physical aches or pains. They tend to have poor self-esteem and irrationally negative thoughts, lose interest in activities and friends, isolate themselves, and feel guilty or worthless for no good reason. Many depressed teens feel hopeless and have recurrent thoughts of death or suicide.

2. Take your child to the pediatrician for a complete physical exam to rule out organic causes of depression.

In some cases, depression is the result of a general medical condition such as hypothyroidism or mononucleosis. Depression can also be a side effect of certain medications. Some teens may exhibit depression as a result of abusing alcohol, drugs, or prescription or over-the-counter medications. Finally, simple things like sleep deprivation, too much stress, and nutritional deficiencies can manifest as depression. It is important that your child receives a complete physical exam in order to rule out any of these potential causes.

3. Let go of guilt and blame.

Depression is no one’s fault. Your child did not choose it and you did not cause it. We know that depression is a heritable brain disorder which is often (though not always) triggered by stressful life events and brain changes during puberty. It is unhelpful, even counterproductive, to blame yourself or your child for her depression. While your child is depressed, her moods and behaviors are to some degree out of her control. She cannot “choose to be happy” or “snap out of it.”

4. Don’t be too quick to medicate.

Psychotropic medication has its place, and under certain circumstances, it may be a very helpful adjunct to psychological treatment for depression. Far too often, however, psychiatrists and other physicians use medication as the first line of defense against depression. This is especially dangerous for children and adolescents, whose brains are still developing and who are more likely to suffer from serious side effects.

In addition to the risk of side effects and the lack of evidence about the long-term effects of antidepressants on a developing brain, there are other dangers to using medicating as the first, or only, line of treatment.

First, there has been very little research on the effects of antidepressants in youth. Second, there is only one antidepressant medication (Prozac) which has been FDA-approved to treat depression in adolescents, but doctors regularly use other medications “off-label” to treat them. Third, psychotherapy is more effective than medication for most adolescents with mild-to-moderate depression. Fourth, a child who receives medication without psychotherapy will not learn the necessary skills or make the necessary life changes needed to sustain lasting improvement and prevent relapse. The effects of medication expire when the medication is stopped, whereas the effects of good psychotherapy are longer-lasting.

In order to protect your child from being prescribed unnecessary or harmful medication, I recommend first taking your child to a psychologist (Ph.D. or Psy.D.) rather than a psychiatrist (M.D.). Psychologists perform psychological assessments and conduct psychotherapy but do not prescribe medication. Most psychiatrists, on the other hand, prescribe medication to the vast majority of patients they see, while conducting little (if any) psychotherapy.

If it becomes evident later on that your child could benefit from medication as an adjunct to psychotherapy, you can always ask your child’s psychologist or pediatrician to refer you to a child psychiatrist with whom he/she has a working relationship.

5. Seek evidence-based psychological treatment.

All therapy is not created equal. Some psychological treatments have been shown to work, while others have not. Research supports the effectiveness of three different types of psychotherapy for depressed adolescents: individual cognitive-behavioral therapy (CBT), group CBT, and interpersonal psychotherapy for adolescents (IPT-A). All three of these treatments are relatively short-term, usually consisting of 12-16 weekly sessions over the course of 3-4 months.

CBT focuses on the relationships among thoughts, feelings, and behaviors. CBT directly targets the adolescent’s present symptoms, without much emphasis on the past. The CBT therapist helps the adolescent identify patterns of thinking and acting which are contributing to her depression and teaches her new ways of thinking and behaving that facilitate positive feelings. CBT be delivered individually, with your child meeting 1-on-1 with a therapist, or in a group consisting of one or two therapists and 6-12 other adolescents who are experiencing depression.

IPT-A focuses on the adolescent’s social functioning and her current relationships with important people in her life. Through IPT-A, the adolescent develops her social skills, learns more effective ways of communicating, identifies connections between certain relationship patterns and her depressive symptoms, and learns to cope effectively with life transitions.

Be conscientious and selective in your search for an appropriate therapist for your child. Try to find a psychologist who has experience in treating adolescent depression. Speak with the psychologist briefly over the phone before making an appointment. Ask her about her philosophy of treatment, and make sure she practices evidence-based treatment.

6. Insist upon being fully informed and actively involved in your child’s treatment.

There is quite a bit you can do to help your child recover from depression, so don’t let any professional tell you otherwise. Treatment works best when you are fully informed and actively involved. Your child will probably be meeting with the therapist individually during most sessions. However, you should be involved in the initial evaluation and treatment planning. You should expect the therapist to check in with you on a regular basis to provide updates on your child’s progress. The therapist should always return your calls in a timely fashion and should definitely tell you if your child is engaging in dangerous behavior.

At the start of treatment, have a frank conversation with the therapist about confidentiality and boundaries. You, the therapist, and your child should come to a clear agreement about what types of information will and will not be disclosed to you as the parent. It is important that your child forms a comfortable, trusting relationship with her therapist. It is even more important, however, that you are made aware of any harmful behaviors (e.g., drug or alcohol use, unprotected sex, eating disorders, cutting) and involved in the process of helping your child overcome these issues.

7. Be willing to consider antidepressant medication under certain circumstances.

Antidepressants are vastly over-prescribed. They should not typically be used as a first-line treatment and should not be prescribed unless the patient is also in psychotherapy. However, there are certain circumstances under which medication may be beneficial and even life-saving:
• If your child has been in evidence-based psychotherapy for two or three months but has not shown any improvement, consider adding an antidepressant to your child’s treatment plan as an adjunct to psychotherapy.
• Depression has a strong genetic component. If your child has a first-degree relative (mother, father, or sibling) who suffers from a mood disorder, this suggests that your child’s depression is likely to be genetic and biologically-based. In this situation, it is more likely that your child will benefit from antidepressants.
• Research has shown that severe depression responds best to a combination of psychotherapy and antidepressant medication. In contrast, mild- to moderate depression can typically be successfully treated with psychotherapy alone. Most cases of depression are mild or moderate, so check with your child’s psychologist to determine the severity of her illness. Adolescents with severe depression are often too ill to engage in psychotherapy without the added benefit of medication to normalize their brain chemistry.
• Your child’s medication should be prescribed and monitored by a board-certified child and adolescent psychiatrist, not by her pediatrician. While pediatricians are able to prescribe antidepressants, they do not have the expertise necessary to monitor your child’s progress and ensure that she is on the correct dose of the right medication.
• You and your child should meet with the psychiatrist for a thorough evaluation before any medication is prescribed. Be sure to ask the psychiatrist about any potential side effects or drug interactions of which you should be aware.
• Your child should be closely monitored by her psychiatrist while she is on the medication, especially during the first month and after a change in dosage. After that, the psychiatrist should follow up with your child at least monthly to monitor her progress and change her dosage if necessary.

8. Create a home environment conducive to overall physical health and mental wellbeing.

Basic self-care habits such as sleep, nutrition, exercise, and stress release are extremely important for someone suffering from depression. Teenagers are notorious for staying up late, eating lots of junk food, and guzzling soda at all hours of the day. While most teens can “get away with” these habits for a few years, teens recovering from depression cannot afford to take shortcuts with their health. Depressive symptoms can be caused or exacerbated by sleep deprivation, poor nutrition, inactivity, and chronic stress.

Prioritize health and well-being above all else. Establish regular bedtimes to ensure that your child gets a minimum of 8 hours of sleep every night. Many adolescents need 9-10 hours of sleep or even more in order to function optimally. Require your child to eat nutritious, balanced meals with the entire family. Supplement her diet with multivitamins and Omega-3 essential fatty acids, which have been shown to improve mood, memory, and general mental functioning. Encourage her to enjoy some physical activity every day. Minimize the stress and tension in your household. Help your child create a balance of study time, personal time, friend time, and family time.

9. Encourage healthy social relationships and fun activities.

Depression causes adolescents to withdraw from their friends and family and lose interest in activities they once enjoyed. Unfortunately, social isolation and inactivity only exacerbate depressive symptoms. Ensure that your child stays connected to the family by sharing meals with the family every day and involving her in a weekly family outing or game night. Encourage her to go out with her friends or invite them over to the house.

See to it that your child is involved in activities that create a sense of purpose, nurture her talents and burgeoning self-concept, and help her connect with other like-minded kids and adults. If your child is artistic, sign her up for art lessons or encourage her to audition for a play. If she is musical, encourage her to join the marching band or take dance classes. If she is athletic, encourage participation on a sports team. Many adolescents find a sense of meaning in volunteer work or involvement in religious activities.

Depressed adolescents often lose motivation and lack the interest and energy to initiate activities on their own. However, once they become involved and engaged in activities, they usually begin to feel a little bit better. Remind your child of this when she expressed reluctance to do something fun or social.

10. Provide your child with plenty of nurturing, comfort, and physical contact.

No parent wants their child to suffer. It will be very difficult to and heart-wrenching to watch your child struggle with depression. However, it is important that you remain calm, steady, compassionate, and optimistic.

Depressed adolescents often feel worthless and guilty for worrying their parents. Tell your child that you love her infinitely and unconditionally, regardless of whether she is happy or depressed. Ensure your child that she is not to blame for being depressed and that she has done nothing wrong. Let her know that you are concerned about her depression, that you are here to support her, and that you will take all the necessary steps to get her good treatment and help her recover.

Physical contact through affection, hugging, kissing can be very comforting to a distraught adolescent. If your child resists being touched, use a soothing voice and reassuring words to comfort her and let her know that you are always available for a hug whenever she needs one. Express empathy towards your child and be willing to listen to her thoughts and feelings. However, you must keep in mind that depressed adolescents may have many irrational thoughts and negative perceptions about themselves and others. For example, your child may be extremely self-critical, believe that no one likes her, tell you her life is a living hell, or fear that you are angry with her. You can gently explain to your child her depression is causing her to see things through a “negative filter” such that many of her perceptions are colored by the depression and are not necessarily accurate.

11. Be patient and realistic.

Recovery from depression takes time. Your child will not feel better right away, nor should you expect her to. It takes weeks for the effects of psychotherapy and medication to become evident. Your child may begin to feel hopeless and worry that she will be depressed forever. This hopelessness is a symptom of depression, rather than an accurate assessment of her situation. You must remain hopeful and optimistic regardless of your child’s attitude. Reassure your child that recovery takes time; that she will begin to feel better soon; that she must stick with treatment.

It is often helpful to lower your standards while your child is depressed. This is difficult for many parents to accept. However, it is important to recognize that depression is a very real and very disabling condition that will have a major impact on your child’s functioning, personality, and behavior. Depression in teens can manifest in a variety of ways. Some teens may suffer a decline in academic performance due to inability to concentrate. Many depressed teens will become quiet and withdrawn; others will become angry and volatile. Some depressed adolescents will act out, abuse drugs, cut themselves, or get into trouble at school. However your child’s depression manifests, be aware of one thing: your child will NOT seem like herself while she is depressed. Just be aware of this fact and accept it. This is not to say that you must tolerate blatant disrespect, delinquency, or dangerous behavior. Continue to maintain appropriate boundaries and limits to keep everyone safe. However, recognize that your child is suffering from a serious mental illness that impairs her ability to function. If her grades slip, or she doesn’t do her chores, or she mouths off to you more than usual, show compassion and empathy, and try to maintain perspective.

Some adolescents experience one episode of depression and that’s it. However, more than half of adolescents who experience major depression will go on to have more episodes in the future. This does not mean that treatment didn’t work, or that your child failed, or that you failed your child. This is simply the nature of major depressive disorder. The good news is that if your child has been successfully treated the first time, you know exactly what to do if she begins to develop symptoms again. With the knowledge, insight, skills, and professional contacts gained the first time around, relapse should be briefer and easier to manage.

Posted on

Everything I Need to Know I Learned From Adolescents

A 31-year-old woman named Monica recently died from anorexia nervosa (AN) following a 15-year battle with the disease. Her death is an eerie reminder of what we already know: eating disorders are dangerous, deadly, and difficult to treat. Traditional treatment for AN typically takes 5-7 years. Less than half of patients with AN will ever fully recover, and of those who do recover, one-third will relapse. Nearly 20% of patients with AN will die as a result of their illness.

Just a decade ago, only 30% of patients fully recovered, and now nearly 50% will fully recover. The reasons for the improved prognosis include greater awareness about eating disorders, which leads to earlier diagnosis and treatment, and the advent of more effective, evidence-based treatment for adolescent AN, such as Maudsley Family-Based Treatment. But early diagnosis, early intervention, and the Maudsley method primarily benefit adolescents. Consequently, I would presume that the 20% increase in recovery rates over the past decade is primarily due to the recovery of more adolescents, not the recovery of more chronically-ill adults.

Although AN typically begins in early adolescence, those who die from the disease are more often adults who have battled it for many years. The most effective course of action is early diagnosis and aggressive, evidence-based treatment as soon as symptoms appear. Unfortunately, there are countless adults with AN who have struggled for years or even decades. As of this time, there are no evidence-based treatments for adults with AN, nor are there any medications which have been proven to benefit adults with AN. CBT has been shown to be moderately beneficial in preventing relapse in weight-restored AN patients but shows no benefit in underweight anorexics.

A lot of the AN treatment offered today is outdated and ineffective. Fortunately, however, there are more and more clinicians and treatment centers who are adopting modern, evidence-based approaches to treating adolescent AN that have much higher success rates. For example, the Kartini Clinic, the UCSD 5-Day Intensive Family Program, and the Children’s Hospital at the University of Chicago have adopted a highly-practical family-based, evidence-based approach to treating adolescent AN based on the Maudsley Method.

We can learn a lot from the success of these adolescent programs. I believe that we can use the basic principles of Maudsley FBT and the philosophy of these adolescent treatment programs to develop effective treatments for adults. Medicine, psychology, and psychiatry do this all the time in the reverse; that is, they extend effective adult treatments to adolescents. If a particular medication or psychotherapy approach demonstrates effectiveness in adults, clinicians automatically begin using it in adolescents, often without any research data to support its use in this population. Clinical trials are then conducted on adolescents, and research data follows.

Consider the basic principles of Maudsley FBT:
1. Conceptualization of AN as a biologically-based brain disorder of unknown origin
2. Externalizing the illness
3. Viewing family members as vital resources in a patient’s recovery
4. Recognition that most of the symptoms of AN are direct result of malnutrition and thus will abate after weight restoration
5. Focus on nutritional rehabilitation and weight restoration as non-negotiable first priorities in treatment
6. Acknowledgment that patients with AN are unable, in the acute phase of illness, to make healthy decisions regarding food and weight
7. Coaching parents to provide emotional and nutritional support to their child
8. Addressing psychological symptoms and other comorbid disorders after weight restoration

Which of these principles are irrelevant in the treatment of adults?

I see no logical reason why we cannot use Maudsley FBT in the treatment of adults with AN. Based on the patient’s circumstance and living situation, spouses, roommates, friends, or significant others may be enlisted for meal support in lieu of parents. The specific details may need to be tweaked in order to be relevant to an adult patient’s situation, but the general principles would remain the same. After all, the physical and psychological symptoms of AN are the same regardless of whether the patient is an adolescent or an adult. AN stunts growth and development and prevent sufferers from becoming independent, fully-functional beings. Thus, adults with AN are regressed physically, sexually, and socially to the point that they often resemble adolescents anyway.

The differences that do exist between adolescent and adult forms of AN are not inherent to the disease itself or even to the age of the patient. Rather, they are imposed by society. We, as a society, have arbitrarily determined that teenagers are fully responsible for their own healthcare decisions once they reach their 18th birthday. This is the case regardless of whether the patient has an ego-syntonic, anosognosic condition such as AN which impairs their judgment and insight. By virtue of their illness, adults with AN are unable to make healthy decisions for themselves. And yet, the law prohibits parental involvement, even parental notification of treatment, unless the patient signs a release. The law clearly sides with AN, not with the patient.

Family support and family involvement are powerful predictors of good outcome. Unfortunately, most therapists consider parental involvement in an adult patient’s treatment unnecessary or even detrimental. These therapists believe that the etiology of AN is rooted in controlling parents, separation anxiety, and issues related to independence and autonomy. Thus, they keep patients separated from the very people who love them most and who may be best equipped to help them achieve full recovery. This is counterproductive because a patient’s physical and psychological wellbeing must always take precedence over the developmental issues of emerging adults which, incidentally, have never been proven to be causally related to AN. Adult patients’ lives are threatened as a result of ignorant adherence to an unproven theory.

I firmly believe that Maudsley Family-Based Treatment can be effective in young adults. In fact, I have used this approach with young adults in my practice with great success. I have seen patients who have been sick for a decade, hospitalized multiple times, and endured several courses of ineffective residential treatment finally achieve recovery as outpatients through FBT. I look forward to the day when FBT is widely available to adults, as well as adolescents, with AN.

Posted on

The Seven Habits of Highly Effective Therapists

What qualities make for an effective therapist? Good listening skills? Yes. Ability to connect and empathize with patients? Sure. A nice person who genuinely cares about you? Absolutely. These qualities may enhance the therapeutic relationship, which is important for healing, but the therapeutic relationship itself does not always translate into recovery, especially for persons with serious mental illnesses. A doctoral degree in psychology, a license to practice, and years of experience in the field indicate that a therapist is qualified, but these things do not guarantee effectiveness.

To put it succinctly, a highly effective therapist is one whose patients get better. Here are the qualities, in my opinion, that highly effective therapists possess.

1. A highly effective therapist conducts a thorough assessment at the start of treatment, including, but not limited to: diagnostic interviews with the patient and her parents (if she is <18), psychosocial / developmental history, family history, medical and psychiatric history, and consultations with the patient’s other treating professionals (e.g., primary care physician, psychiatrist). She synthesizes this information to arrive at an accurate diagnosis. She is cognizant of the multifaceted etiology of mental disorders, and takes into account genetics, biology, temperament, psychosocial issues, environmental factors, lifestyle and behaviors (e.g., stress, sleep, nutrition, exercise) when determining the cause(s) of the patient’s problems. 2. At the end of the initial assessment, a highly effective therapist has an in-depth discussion with the patient, and the parents of minor patients, in which diagnostic impressions are shared. The therapist provides the patient and her family with a scientifically-grounded explanation of her disorder(s) and explains the full range of treatment options available.

3. In collaboration with the patient, and parents of minor patients, the highly effective therapist develops a treatment plan. This treatment plan may consist of services delivered by other professionals (e.g., psychiatrist, pediatrician, dietician) and may consist of one or more modalities of treatment (e.g., individual therapy, family therapy, group therapy). Parental involvement is an integral part of the treatment plan for children and adolescents, except in rare cases when parental involvement may be contraindicated. For adult patients, family members are often included in the treatment plan to participate in family therapy or to play a support role. The highly effective therapist coordinates the patient’s treatment with the other professionals on her treatment team and maintains regular contact with all team members throughout the patient’s course of treatment.

4. A highly effective therapist has training and experience in empirically-supported treatments, such as CBT, DBT, ACT, Maudsley FBT, and IPT. She stays abreast of recent developments in the etiology and treatment of the disorders she treats so that she may better serve her patients. She uses empirically-supported treatments with her patients unless contraindicated.

5. A highly effective therapist is well-prepared and fully present, in body and in mind, with her patients. Therefore, the highly effective therapist is not over-scheduled or over-stressed. She has enough time in her schedule to meet with every patient as often as necessary, including last-minute emergency appointments when needed. She has adequate time to devote to preparing treatment interventions, adequate record keeping, maintaining regular contact with other professionals, and returning patients’ calls and emails in a timely fashion. The highly effective therapist demonstrates respect for her patients’ time by starting and ending appointments promptly and refraining from canceling or rescheduling sessions in the absence of a true emergency. She has sufficient flexibility in her schedule so that, if a patient must cancel a session, she can reschedule the patient within the week. The highly effective therapist devotes her full attention to her patient during sessions by turning off her phone, not responding to emails, and not allowing visitors to knock on the door.

6. A highly effective therapist knows when, and when not, to refer her patients to psychiatrists. She knows which symptoms and disorders usually require medication and which symptoms and disorders can be treated solely with behavioral or psychological interventions. She is conservative in her approach to psychotropic medication and views it as an adjunct to effective psychotherapy. She prefers for her patients to be on medication only when necessary, and on as little medication as necessary for optimal functioning. A psychiatric referral almost always results in medication prescribed. Thus, a highly effective therapist refers patients to psychiatrists only if there is evidence that psychological interventions alone will not be sufficient for recovery. When a psychiatric referral is indicated, a highly effective therapist obtains a signed release of information from the patient to communicate with the psychiatrist. Thereafter, the highly effective therapist maintains communication with the psychiatrist for the duration of the patient’s treatment and is closely involved with decisions to start, stop, and change dosage of the patient’s medications.

7. A highly effective therapist terminates treatment at the appropriate time and in the appropriate manner. Typically, therapy is over when the patient has reached maximum benefit. Sometimes treatment must be terminated because a patient is not progressing. At this point, the therapist assists the patient in formulating a plan for future care. When it is clear that a patient requires a higher level of care than the therapist can provide (e.g., residential or inpatient treatment), she makes the appropriate referrals and supports the patient in following through with these referrals. She does not allow the patient to settle for a lower level of care than she requires. Regardless of the reason treatment ends, the therapist provides the patient with the opportunity to create meaning out of her therapeutic experience. At the end of treatment, the therapist allows at least two sessions for the patient to reflect on her experience in therapy, the progress that she has made, and the therapeutic relationship.

Posted on

How to Choose a Therapist

A good therapist is hard to find. I’m new to the field, relatively speaking, and I’ve already encountered a number of horrible therapists as well as many outstanding ones.

Finding a good therapist is trickier than finding a good dentist or gynecologist. Most people choose their healthcare providers based on a three simple factors: proximity to their home or work, whether the provider takes their insurance, and personal recommendations. For most healthcare issues, this works out well. After all, a biannual dental cleaning is a biannual dental cleaning; a pap smear is a pap smear – there’s not a whole lot of variation in how these procedures are done. You can be pretty confident that you’re getting decent care regardless of which doctor you choose. If you don’t like your doctor, no big deal – you only see her once or twice a year, and besides, she takes your insurance and she’s two blocks away from your office! You may opt to switch doctors due to a negative experience with one or a change in insurance coverage, but this is not a big deal either. You just go back to square one and choose someone based on those initial three criteria.

Choosing a therapist is not so simple. Therapists are not interchangeable like dermatologists or orthodontists. The treatment you get with one therapist differs tremendously – in terms of the nature of treatment, the type of treatment, and the quality of treatment – from the treatment you would get with other therapists. The problem is that most people outside the field are not aware of this, and it is difficult to find out what you are getting before you get it. The licensing process does very little to weed out incompetent psychologists. The two written exams we must pass – one based on a general knowledge of psychology and one based on state laws and rules for psychologists – have no predictive validity in determining whether someone is a good therapist. Basically, therapists can do whatever they want in their sessions, so long as it doesn’t violate ethical codes. Therapists are not prohibited from practicing outdated, ineffective treatments. Although research has shown certain psychological treatments to be vastly superior to others for certain disorders, the majority of therapists do not use these empirically-supported treatments.

Choosing a therapist based on proximity alone is not a good idea. The therapist closest to you may not be a good fit for you. Choosing a therapist based on insurance alone is also not a good idea because many therapists don’t take insurance. Further, if you do use your insurance to pay for treatment, the insurance company will likely request a great deal of personal information about your mental health conditions, may discriminate against you based on diagnosis (or lack thereof), and will probably limit the number of sessions you can receive. Getting personal recommendations for therapists is tricky because it involves disclosing at least some personal information to a friend or colleague, and many people are not comfortable doing that. It is not always wise to choose a therapist based on how much experience she has in the field, because many therapists who have been practicing for decades remain entrenched in antiquated theories of mental disorders and practice less effective treatments Also, if you are a young person, it may feel more comfortable to talk to someone closer to your age who can relate to you more easily and who has a better understanding of your generational issues.

So how do you choose a therapist? Well, that depends on why you’re seeking therapy. If you need some support in dealing with normal developmental or social stressors (e.g., death of a friend or family member, relationship issues, stress management, divorce or breakup, difficult transitions), it is helpful to use the following selection criteria:

• A personal recommendation from a trusted friend may be helpful in this case.

• Find someone who has experience dealing with the types of issues you are facing. For example, if your sibling just died, find a therapist who is experienced in working with grief.

• Consider whether you have a preference in terms of your therapist’s gender, ethnicity, age, or sexuality. Many people prefer to work with a therapist of their same gender and/or someone who is close to their age. Many LGBT clients prefer therapists who are openly gay or lesbian, or who have considerable experience working with these populations. Some ethnic minority individuals prefer working with someone who shares their ethnic background. On the other hand, some clients don’t have demographic preferences, and that’s OK too.

• Find a therapist with whom you feel comfortable. You may need to have a session or two with the therapist before really being able to tell whether it is a “good fit.” Developing a strong, trusting therapeutic alliance will facilitate the healing process.

• Find a therapist who is a clinical psychologist (Ph.D. or Psy.D.), Licensed Mental Health Counselor (LMHC), Licensed Clinical Social Worker (LCSW), or Marriage and Family Therapist (MFT).

When you are seeking treatment for a mental illness, such as major depressive disorder, OCD, anorexia nervosa, PTSD, or borderline personality disorder, I would recommend using a different (and more stringent) set of selection criteria because the stakes are higher. Having a good therapist is a powerful predictor of your chances for recovery, so it is important to take the therapist selection process seriously. Most therapists offer free phone consultations in which you can briefly describe your issues and ask about her qualifications and approach to treatment. I recommend using the following selection criteria in choosing a therapist to treat a mental illness:

• Do as much research as you can on your diagnosis and effective method(s) of treating your particular condition.

• Look for a therapist who specializes in providing evidence-based treatment for your disorder. For example, if you suffer from OCD, you will want to find a therapist who specializes in OCD and practices behavior therapy. You can find out this information by looking on the therapist’s website (if she has one) or simply by calling to ask her about her specialties and her treatment approach.

• Ask the therapist about her views on your particular disorder and the treatment thereof. If her explanation of your illness is unscientific (e.g., “Anxiety disorders are the result of unresolved inner conflicts”) or if her treatment approach sounds flaky or non-directive (e.g., “I provide clients with a safe place in which they can explore their issues”), move on to someone else. It’s great to explore your issues in a safe place, and this may be exactly what you need when struggling with the normal developmental or social stressors described above. If you have a mental illness, however, you’re going to need a whole lot more than that in order to recover.

• Look for a therapist with a doctoral degree in psychology (Ph.D. or Psy.D.). Doctoral level psychologists have 5-7 years of graduate training and supervised clinical practice, plus a post-doctoral residency. Most Ph.D. programs in clinical psychology are extremely selective and have very low acceptance rates (for example, 250 applications for 6 slots). In addition, Ph.D. psychologists have extensive training and experience in scientific research. While a Ph.D. in clinical psychology does not guarantee therapeutic effectiveness, it does reflect a high level of ambition and academic accomplishment, a scientific background, and at least five years of intensive, high-quality training. In contrast, a master’s level therapist such as a social worker (LCSW), licensed mental health counselor (LMHC) or marriage and family therapist (MFT) has significantly less clinical training (usually 2 years of graduate school) and very little, if any, training in scientific research. Psychiatrists are medical doctors (MD’s) who focus primarily on prescribing psychotropic medication. Some of them provide psychotherapy in addition to medication, but most do not. Their training is primarily in the practice of medicine, not scientific research or psychotherapy. Most psychiatrists these days have little training in psychotherapy. Of course, there are exceptions to this rule. If you decide to see a psychiatrist for therapy, make sure she is one of the exceptions.

• University-based mental health clinics and academic medical centers are excellent places to seek psychological treatment. Many of them offer low-cost services or provide treatment for free as part of research studies. The therapists are typically doctoral-level graduate students, pre-doctoral psychology interns, and/or post-doctoral residents, all of whom are closely supervised by licensed clinical psychologists. Advanced graduate students, interns, and post-docs tend to make excellent therapists because they are young, idealistic, energetic, fully informed about recent advances in the research and practice of therapy, well-trained, and constantly evaluated on their performance.

• Find a therapist whose patients actually recover. The proof is in the pudding. Ask the therapist how many patients with your diagnosis she has treated in the past three years, and how many of those patients have fully recovered. If she hems and haws, or describes therapy as a lifelong journey, or claims that one never recovers from your particular disorder, move on to someone else.

• If the therapist is empathic, great. If she’s really nice and makes you feel at ease, wonderful. If you feel very connected to her, fantastic. These qualities are important, but if you are struggling with a mental illness, what matters most is whether she can help you recover. Mental illnesses are treatable and manageable; some are even curable. So don’t mess around with your mental health care. If you had cancer, your priority would not be finding an oncologist who was warm and kind and empathic and emotionally connected to you. These qualities are icing on the cake, but what you need most of all is the cake. And the cake is effective treatment that will cure your cancer. Don’t need to settle for anything less in your mental health care.

Posted on

Top 10 Mistakes in Mental Health Care

Very early in my blogging career, I wrote about The Top 10 Mistakes in Eating Disorders Treatment. Bad treatment, however, is not limited to eating disorders. Here are the most common mistakes I have observed in the treatment of other mental illnesses:

1. Failure to conduct a thorough assessment at the beginning of treatment. This contributes to missed diagnoses, incorrect diagnoses, and ultimately to ineffective or inappropriate treatment.

2. Failure to assess for behavioral, lifestyle, and environmental factors that may be contributing to the patient’s symptoms. This generally corresponds with the failure to recommend simple lifestyle changes which have a powerful impact on psychological wellbeing. Sleep deprivation, excess alcohol or caffeine intake, lack of exercise, poor nutrition, and increased stress at work, school, or home create symptoms that appear identical to those of depression and anxiety. For many people, these symptoms can be alleviated by making behavioral changes. For others, psychotherapy and medication may be necessary.

3. Lack of basic, scientifically-sound education for patients and their families regarding the patient’s disorder(s) and the efficacy of various treatment options. It never ceases to amaze me how many patients and families come to me, after months or years of therapy, without a basic science-based explanation of their mental illness, and without ever being informed that evidence-based treatment exists. Perhaps the most common example of this phenomenon is the patient whose four years of previous therapy focused on the “why” or the “root cause” of her mental disorder without providing any symptom relief. Insight is important, but insight itself does not cure mental illness. These patients are not provided with the simple (and in my mind, very liberating) explanation that mental illnesses are caused by certain biological and genetic vulnerabilities which are often expressed when certain environmental circumstances are present. They are not told that, regardless of the reasons why they developed their illness, they can learn skills to help them manage their symptoms and feel better.

4. Failure to use effective, evidence-based psychological treatments (EBT’s). For the majority of mental illnesses, there is research demonstrating which treatments are most effective. The problem is that the majority of therapists do not use EBT’s. There are several reasons for this: A.) Some therapists have not been trained in evidence-based treatments. This is the result of a three-pronged failure: on the part of the graduate programs which do not teach EBT’s, on the part of the therapists who do not take the initiative to keep up with the literature or seek out the proper continuing education courses, and on the part of the state licensing boards, which do not require that therapists learn about or practice EBTs. B.) Some therapists have been trained in EBT’s but choose not to use them because they value their own clinical judgment more than they value science. This is faulty logic, because research shows that statistical prediction consistently outperforms clinical judgment. Translation: therapists are far more effective when they select their interventions on the basis of scientific research (e.g., what works best for most people with this particular disorder) rather than using their own judgment to decide how to help a patient. C.) Some therapists protest: “But EBT’s don’t work for everyone.” Well, of course they don’t. Nothing works for everyone. But if research consistently shows that treatment A is effective for 80% of people with OCD, while treatment B is effective for 25% of people with OCD, and treatment C is based upon a psychological theory but has never been studied scientifically, it’s a no brainer. Use treatment A with OCD patients unless you have a specific, convincing reason not to. It makes no logical, mathematical, ethical, or scientific sense to do otherwise.

5. Insufficient amount or intensity of psychological treatment. Sessions may begin too late in the course of a mental illness; sessions may be held less frequently than needed; treatment may be terminated before the patient is fully recovered; patients may not receive the level of care (e.g., hospitalization, residential treatment, day treatment) that they need in order to recover. Financial issues and insurance limits are largely to blame for this problem. However, our attitudes about mental illness and personal autonomy play a major role as well. I don’t believe in the “least restrictive environment” criterion. I do not believe that a person should have to be imminently suicidal, homicidal, or floridly psychotic to warrant inpatient treatment. I do not believe that residential and day treatment programs should be reserved for those who have had multiple failed attempts at outpatient treatment. I believe that providing intensive, aggressive treatment at initial diagnosis (which often requires more than your typical weekly therapy sessions) would greatly reduce the severity and duration of mental illnesses.

6. Focusing on “underlying issues” rather than symptoms early in treatment. It makes no sense to do intensive psychotherapy with a drug addict while she is high or while she is actively using drugs. Her mental state is too compromised for her to do meaningful psychological work, and the psychological work detracts time and attention away from the most glaring, life-threatening problem: the drug use. This patient would need to go through detox and rehab before she could really benefit from psychotherapy. Similarly, if a person is severely depressed, severely anxious, or engaging in self-injurious behavior, it makes no sense to spend the therapy hour processing inner conflicts or exploring childhood memories. She cannot think rationally or process emotional information accurately while such acute symptoms are present. The first step must be to alleviate the symptoms. To do otherwise simply serves to delay her recovery and prolong her misery.

7. Failure to address underlying issues, if they exist, later in treatment. Once symptoms are under control, it is important to assess for and treat any underlying issues which could make the patient vulnerable to relapse. I do not mean to imply that every patient has deep, dark secrets of trauma or major internal conflicts. Many patients have simpler underlying problems, such as poor communication skills, unhelpful relationship patterns, low self-esteem, perfectionism, unhealthy core beliefs, or overly stressful jobs or home lives. Regardless of the nature of the patient’s issues, they must be treated if the patient is to heal fully and maintain a lasting recovery. Disclaimer: It is a huge mistake for therapists to presume that all patients have serious underlying issues that must be addressed in treatment. This assumption leads to endless exploration of the past, digging around for some buried treasure that often does not exist. This can be a waste of time and money, can lead to over-focus on the past at the exclusion of full engagement in the present, and can actually make patients feel worse. Sometimes a cigar is just a cigar.

8. Over-prescribing, or inappropriately prescribing, psychotropic medication. A lot of this has to do with insurance companies and financial issues: it is cheaper to medicate than to treat holistically with psychological therapy, at least in the short term. We know that for many mental illnesses, certain evidence-based psychological treatments are more effective than medications (i.e., DBT for borderline personality disorder, CBT, ACT, and exercise for mild to moderate depression, exposure and response prevention for OCD, behavior therapy for panic disorder, CBT-E for bulimia nervosa). And yet many patients are medicated for these illnesses without being offered psychological treatment, and without being informed that certain psychological treatments for certain conditions are actually superior to medication. Recent statistics show that 80% of prescriptions for psychotropic medications are written by general care physicians (internists and pediatricians). This appalls me. While GPs are allowed to prescribe psychotropic medication, they lack specialized training in the diagnosis and treatment of mental illness. The ideal situation is for a psychiatrist to prescribe the psychotropic medication, follow up with the patient regularly to monitor her response to the medication, and remain in close contact with the patient’s GP and therapist in order to ensure seamless coordination of care.

9. Failure to involve family members in a young patient’s treatment. Yes, the primary developmental task of adolescence is separation / individuation. But this developmental reality in no way precludes involving family members in an adolescent’s treatment. I believe that a child or adolescent’s treatment works best when family members are fully informed and actively involved. The patient may be with the therapist for 1 hour a week, but she is with her family for the other 167 hours. Therapists are most effective when they strengthen a family unit (rather than weakening it by pointing the finger of blame), communicate openly with parents (rather than hiding behind the cloak of confidentiality), and provide them with tools to help their children (rather than urging them to back off). Therapy is temporary; family is forever.

10. Blaming patients, either subtly or overtly, for their mental illnesses. This causes so much harm. Many therapists are of the opinion that if patients just tried a little harder, dug a little deeper, or stayed in therapy just a few months (or years) longer, they would get better. Patients are often held responsible for their own lack of therapeutic progress (Remember the old joke – “How many shrinks does it take to change a light bulb? Just one, but the light bulb has to WANT to change”). As a result, patients blame themselves when they do not recover. Guilt is paralyzing and depressing and disempowering. In what other illness would a patient be held responsible for her lack of improvement? Obviously, therapy is a collaborative process which requires tremendous courage and dedication from the patient. That said, the therapist is responsible for providing the patient with effective treatment and guiding her towards recovery.

Posted on

What’s Wrong With Mental Health Care in America?

Just about everything.

I can sum up our country’s mental health care problem in one sentence: Failure to provide local, high-quality, comprehensive, affordable, evidence-based mental healthcare for every American citizen, at the appropriate level of intensity, for as long as necessary for full recovery and relapse prevention.

Few Americans have access to local high-quality, evidence-based mental healthcare. Some people find mental health care cost-prohibitive. Others struggle to make ends meet, dipping into their savings, wiping out their retirement accounts or college funds in order to afford appropriate mental health treatment for themselves or their loved ones.

Societal ignorance is partially to blame for this problem. Although “the stigma” of mental illness has allegedly been reduced in recent decades, I see it all around. Like racism and sexism, the stigma of mental illness is perhaps less overt now than it was in previous generations, but it is alive and well today in all of its subtler forms. Many insurance plans do not provide coverage for mental health care. This conveys the message that mental health treatment somehow optional, unimportant, or extracurricular. The brain is arguably the most important part of the body, so why should treatment of brain diseases be viewed as less essential than ophthalmology, endocrinology, or dermatology?

Even more infuriating to me is the reality that mental illness itself is not nearly as stigmatizing as GETTING TREATMENT FOR MENTAL ILLNESS. Consider the following:

• As a graduate student, I read about a medical insurance policy that parents of college students can take out for their children. This policy allows parents to receive a full tuition refund if their child withdraws from school mid-semester for medical reasons. However, the policy specified that, if the student withdraws due to “a nervous or mental disorder,” the parents would receive only a 60% refund. The implication here, as I see it, is that students with mono or renal failure or cancer have “legitimate” illnesses that are neither their fault nor their choice, whereas students with bipolar disorder or anorexia nervosa or major depression are at least partially to blame for their problems, which are seen as less “real,” and they could stick it out for the rest of the semester if they really wanted to. This policy creates a situation in which students struggling with severe mental illnesses feel pressured to remain at school, away from their primary support system, with inadequate treatment, for the duration of the semester, rather than returning home to their families to recover and pursue more intensive treatment.

• Many universities require students who have been out on medical leave for mental health reasons to have a readmission assessment with a mental health professional before being permitted to matriculate once again. Students who were out on medical leave for physical illnesses are not required to submit to a physical exam upon their return to school.

• In the state of Florida (and perhaps in other states), aspiring attorneys must answer a question on their bar application asking whether they have had treatment for a mental disorder. [OBJECTION, YOUR HONOR! RELEVANCE?] If they answer “yes” (and they must answer truthfully under penalty of perjury, they must submit a letter to the bar from their treatment provider describing the nature of their symptoms and course of treatment. Law school is a virtual breeding ground for depression, anxiety, substance abuse, and various stress-related ailments, but many law students will not seek treatment because they don’t want their law careers to be jeopardized by answering “yes” to that question. And I can’t say that I blame them.

• Some adoption agencies, particularly those that deal with international adoptions, categorically refuse to consider individuals who have been diagnosed with or treated for any mental disorder as potential adoptive parents. For example, taking medication for any mental illness, including anxiety or depression, automatically disqualifies hopeful adoptive parents from adopting Chinese orphans. Because, of course, isn’t it better for a child to grow up in an impoverished orphanage without access to modern medical care or higher education, rather than in a loving, stable home with a dad or mom who has responsibly sought treatment for A VERY COMMON, VERY TREATABLE MEDICAL CONDITION? Notably, having an undiagnosed, untreated mental illness does not disqualify potential adoptive parents from adopting Chinese orphans. This policy clearly discriminates against those who have sought treatment.

• Receiving mental health treatment is potentially damaging to a soldier’s military career. This creates a catch-22, because the very act of serving in the military during times of war is a huge trigger for mental illnesses like PTSD, depression, and substance abuse. Few people escape from deadly combat without some mental scars. Yet seeking treatment and risking a diagnosis of a mental disorder is too risky, and too humiliating, for those who have made a career out of protecting and defending our country.

In each of these instances, people who do not seek treatment for their symptoms seem to have a distinct advantage over those who do. For what other disease is it preferable to stay sick than to get healthy? People with mental illnesses who receive good treatment obviously fare better, on the whole, than those who receive no treatment or insufficient treatment. The ultimate irony here is that many people who have been treated for mental illnesses are at least as “mentally fit” as people without mental illnesses, if not more so, BECAUSE they have been through treatment. In general, those who seek out and receive good mental health treatment tend to develop more self-awareness, better coping skills, and a more positive perspective. Certainly these qualities are beneficial to a student, an attorney, a parent, or a soldier.

The National Institute of Mental Health estimates that more than ¼ of American adults suffer from a DSM-IV diagnosable mental disorder in any given year. Further, mental disorders are the leading cause of disability in the US and Canada for individuals ages 15-44. Most upsettingly, only 41% of Americans with diagnosable mental disorders have received any mental health treatment at all in the previous 12-month period. The vast majority of mental illnesses are treatable and manageable – and some are even curable – when the patient receives appropriate care. Imagine how many lives are destroyed, how much productivity is lost, and how much suffering is perpetuated not by mental illness per se, but by people’s refusal or inability to get proper mental health care.

At times, the state of affairs in mental health care looks so bleak that I ask myself why I have chosen this field. My conclusion: the awful state of mental health care is precisely the reason why I have chosen this field. As I ponder this issue, I am reminded of an inspiring quotation from Neale Donald Walsch: “Be a light unto the darkness, and curse it not.” I’m doing my very best to be a light unto the darkness. It’s the “curse it not” that I find much more challenging.