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Confidentiality in Adolescent Psychotherapy

Confidentiality is a cornerstone of the therapeutic relationship. The ethics of my profession require that all communication between my patients and me remains confidential. In other words, I cannot disclose the information a patient reveals in session, or my own impressions about a patient, to anyone without the patient’s explicit written consent. Of course, there are exceptions to the rule. I am a mandated reporter of child abuse, and if a patient is imminently suicidal or homicidal, I have a duty to notify the appropriate parties in order to save the patient’s life and protect the public. But these scenarios are relatively uncommon.

Undoubtedly, confidentiality is an important, if not essential, therapeutic tool. Patients are far more likely to enter therapy, and to be completely honest and forthcoming in therapy, when they know that “what happens in therapy stays in therapy.” I am honored and humbled, though not necessarily surprised, when a patient tells me that I am the first person she has ever told about a particular trauma, event, thought, or feeling. A therapist’s office is a safe place in which a patient can express anything and everything without fear of judgment, alienation, or other negative repercussions. Through this vulnerability and brutal honesty comes an opportunity for growth and meaningful change.

However, confidentiality is not without its problems. For example, psychologists often struggle with decisions as to whether to disclose information about adolescent patients to their parents. On the one hand, parents have a legal right to obtain health care information regarding their child, and they are technically the “holders” of any privileged communication between their child and her therapist. On the other hand, adolescents can undoubtedly benefit from discussing certain personal issues with a nonjudgmental third party outside their family, and they are less likely to raise such issues with their therapist if they know that the information will get back to mom and dad.

I know of some psychologists who share very little with the parents of their adolescent patients. After all, they argue, the primary developmental tasks of adolescence include separation from family and establishment of an independent identity. These psychologists believe that they are respecting the adolescent’s burgeoning sense of identity by excluding parents from treatment. They also believe that they are nurturing the therapeutic relationship by refusing to disclose all but the most essential information to an adolescent’s parents. Many of these therapists believe that the parents are guilty of causing or contributing to their child’s problems, and thus are best kept out of the treatment picture. As a result, many parents of adolescent patients are relegated to the role of chauffeur. They drive their child to her appointments and pay for her treatment without ever knowing what is going on in those sessions. Imagine how disempowering it must feel for a parent to be relegated to such a role.

To be sure, psychologists who practice this way make many valid points. However, I have a different perspective on my role as a therapist and on the role confidentiality plays in my work with adolescent patients. Consequently, I approach the issue of confidentiality with adolescent patients differently. Empirical research has demonstrated, and my own clinical experience has confirmed, that adolescent treatment generally works best when parents are fully informed and actively involved, and I communicate this point to my adolescent patients and their parents at the start of our work together. I am relatively unconcerned when I meet an adolescent patient who lacks insight or motivation or who resists treatment. I am very concerned when the parents of an adolescent patient are unwilling, unmotivated, or unable to play an active role in their child’s treatment.

When I work with adolescents with relatively normal social or developmental concerns (e.g., grief, problems with friends, sexuality, stress management, body dissatisfaction), parents play an important, though relatively minor, role in treatment. In these cases, the work is primarily between the adolescent and me. Even so, I involve parents in the initial evaluation, treatment planning, and discharge planning; I provide them with empirical literature on their child’s problem and the treatment approach I am using; I provide them with guidance as to how they can support their child at home; and I invite them to call me or schedule an appointment with me at any time if they have questions or concerns about their child.

In my work with adolescents with mental illnesses, parents play a central role as indispensable members of the treatment team. I take an authoritative stance regarding my knowledge of, say, major depression or anorexia nervosa, while also maintaining humility by respecting parents’ judgment and intuition regarding their child. I may be the expert on mental health, but they are the experts on their child.

Adolescents who are struggling with serious mental illnesses, such as bipolar disorder, major depression, anorexia nervosa, and bulimia nervosa, require treatment which is more intensive and more comprehensive. These patients need their parents to play an active role in managing their symptoms and creating an environment which is conducive to recovery. In order for parents to do this, they need to be informed about their child’s symptoms and progress. While I certainly do not share everything a teenage patient says in therapy with her parents, I do provide her parents with the information they need in order to help her get better.

The parents of adolescents with mental illnesses are often overly stressed, worried, isolated, and confused. These parents need considerable support, encouragement, and guidance as they learn to cope with their child’s illness and support her through her recovery. This one of the reasons why I am so fond of family-based treatment: I get to empower the family to support the patient, drawing upon the parents’ intimate knowledge of and investment in their child. Instead of pulling the patient away from her family, I strengthen her natural support system, which makes intuitive sense to me. After all, therapy is time-limited. Family is forever.

Family members are also vital in preventing relapse, as they are generally the first people to notice a change in their child’s mood or behavior. Equipped with the right knowledge and skills, parents can intervene immediately and help to pull their child back from the brink of relapse, often preventing the need for future treatment.

Does involving family members in treatment damage my relationship with my adolescent patients? In the short term, it often does. Keep in mind, though, that some families bring their adolescents to me after an unsuccessful course of traditional individual therapy in which the patient had a very special, exclusive relationship with her therapist (who may have implicated her parents in the etiology of her problems) but made no meaningful progress whatsoever. My therapeutic relationship with adolescent patients is certainly important, but it is far less important than strengthening her relationship with her family and taking the necessary steps to help her recover. As adolescent patients progress through recovery and gain more insight, they gain trust in me and in their parents. They gain faith in the recovery process, and most of them are grateful for the fact that their parents and I worked collaboratively to help them. As much as they may resist it, adolescents need boundaries and limits, and they need adults to work together on their behalf.

By involving parents so heavily in an adolescent’s treatment, am I disrupting the processes of separation and individuation? In the short term, yes. I would argue, however, that cutting, starving oneself, engaging in unprotected sex, and throwing up after meals are not acceptable ways of exerting control or establishing identity. The supposition that a certain unhealthy behavior serves a valuable emotional or developmental purpose does not justify allowing that behavior to go unchecked. It is the mental illness which hinders adolescent development, not the treatment. Adolescents struggling with crippling depression or anxiety, erratic mood swings, self-injury, or life-threatening eating disorders are unlikely to blossom into well-adjusted, independent young adults without significant support. Empowering an adolescent’s parents to help her overcome a mental illness is ultimately very respectful of adolescent development – it allows the patient to recover within the safety and security of her natural environment so that she may one day live independently, unencumbered by mental illness.

For these reasons, my relationship with the parents is just as important as my relationship with the adolescent patient. Parents need to trust my judgment and treatment methods. They are, after all, entrusting me with their child’s health and bright future. I believe that I earn parents’ trust by maintaining open lines of communication between us, by providing them with empirically-sound literature on their child’s condition and the treatment approach we are taking, by respecting their parental instincts and taking seriously their experiences with their child, by supporting them emotionally, by absolving them of guilt and self-blame for their child’s disorder, and by empowering them to take constructive action.

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Palliative Care for Anorexia Nervosa?

I recently read an article in the International Journal of Eating Disorders entitled Managing the Chronic, Treatment-Resistant Patient with Anorexia Nervosa (Strober, 2004). Though eloquently written and artfully persuasive, this was probably the most depressing journal article I have ever read. The author, Michael Strober, seeks to help readers “resolve the paradox of caring for patients who seem so decidedly opposed to change.” Essentially, Strober advises psychologists to avoid pushing, or even encouraging, full nutrition and weight restoration in chronically ill patients with AN because these attempts will backfire by upsetting the patient emotionally and thus leading to premature termination of therapy. Instead, he argues, therapists “can expect little, should seek nothing, and must largely defer to the patient in regards to the objective of the time shared together.”

Strober states that the therapist’s attempts to encourage re-feeding “will feel like an assault” to the patient and are “certain to induce peril.” He warns therapists that their efforts to coerce patients into hospitalization or other much-needed medical care will result in “a potentially dangerous exacerbation of symptoms.” The article presents two tragic case studies of women in their late 20’s who have been chronically ill with AN since early adolescence. Each story is presented as a cautionary tale describing the deleterious effects of requiring full nutrition and weight restoration in these types of patients. Finally, Strober admonishes therapists to be aware of their counter-transference with such patients and advises them to “concede the reality that there may be little to do to drastically alter the course of a patient’s illness,” and notes that “this is neither failure nor inferiority.”

I view this entire philosophy as a manifestation of both failure and inferiority. Failure on the part of professionals who fear an emaciated patient’s wrath more than they fear her death. Failure on the part of a profession which espouses the dogma that avoiding premature termination of treatment is more important than avoiding premature termination of the patient’s life. Failure on the part of a philosophy that values nurturing the therapeutic relationship more than it values giving a patient a fighting chance at life, health, and happiness. These patients have not failed treatment. Treatment has failed them.

Strober argues that there is a place in our field for palliative care for treatment-resistant anorexics. I disagree. Anorexia nervosa is, by definition, resistant to treatment. The “peril” that ensues during re-feeding is real and universal. Re-feeding is agonizing for the patient herself, her friends and family, and her treatment team. Anyone who has ever made the heroic journey from AN to recovery will tell you that. I have never met an anorexic who gladly relinquished rigid control over her diet, voluntarily prepared and consumed high-calorie meals, and excitedly welcomed weight restoration without struggle. A person such as this would not have been diagnosed with AN in the first place. Chronically ill patients with AN are not resistant to treatment. Treatment is resistant to them.

Towards the end of the article, Strober warns therapists to keep their counter-transference in check by not pushing patients too hard, not expecting recovery, and resigning themselves to the reality that these patients are destined for a lifetime of illness and misery followed by a premature death. He notes that many therapists are not well-suited for providing palliative care to treatment-resistant anorexics. I, for one, am certainly not cut out for that type of work. I am not able to sit impassively with a patient who has been ill for fifteen years without taking draconian measures to propel her towards health. I recognize that responsibility for her recovery, at least initially, lies with me and with her family. I would not expect a patient with that level of illness to embrace recovery. That’s my job, not hers.

Individuals with AN are almost universally brilliant, talented, sensitive, and intense. They have so much potential, so many gifts to offer the world. They are physicians and nurses and lawyers, scientists and professors and teachers. They are outstanding athletes, writers, singers, dancers, actresses, and artists. Consider three-time Grammy-winning singer Karen Carpenter who died of AN at age 33 and world-class gymnast Christy Henrich, who died of AN at age 22. These women were beloved daughters, loyal sisters, caring friends.

It baffles me that, in a society which purports to value human life, we allow these precious lives slip away. The Bush administration placed restrictions on stem-cell research, supposedly out of concern for the sanctity of life. Nearly half of Americans are opposed to abortion. Our society believes that elderly, terminally ill patients in excruciating pain must not be allowed to die, as evidenced by the fact that doctor-assisted suicide is illegal in every state except Oregon. States have laws which allow for the involuntary hospitalization of imminently suicidal and floridly psychotic patients, recognizing that these individuals are not well enough to care for themselves. Psychiatric hospitals use 4-point restraints, sedatives, and padded rooms to prevent patients from injuring themselves. Prisoners are forbidden from having sharp objects and belts in order to protect them from taking their own lives. Death row inmates who attempt suicide are resuscitated. Don’t we owe the same to innocent people who are suffering from a horrible eating disorder?

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Redefining Strength

All too often, we confuse strength with stoicism. We see an apparent absence of negative emotions and presume courage. We see an unadulterated expression of sadness and assume fragility.

I see this sometimes with new therapy clients. Like most of us, they’ve bought into the American dream (or American nightmare), where hard work, free will, and rugged individualism are viewed as keys to success and anything less is perceived as weakness or failure. When I ask how they feel about entering therapy, they report feeling weak for needing professional help, and even weaker if they are referred for psychiatric medication or a higher level of care. They feel ashamed when they cry in a therapy session, and they apologize to me. They berate themselves for not being strong enough to handle their mental illness, or the bad hand of cards they were dealt in life, on their own. They chide themselves for letting a breakup erode their confidence, for bursting into tears after being admonished by their boss, for letting life’s twists and turns and ups and downs affect them at all.

Taken to its logical extreme, this line of thought implies that it is a sign of weakness to experience and / or express negative emotions; strong people never experience negative emotions, or if they do, they suppress them; and strong people solve all of their problems on their own, without leaning on friends or family, and certainly without seeking professional help.

In reality, none of these statements are true. Vulnerability should not be confused with fragility. Experiencing and expressing a full range of emotions is not a sign of weakness. It is a manifestation of humanity.

My view of strength is quite different. In my mind, a strong person is someone who has a well-defined set of personal values and uses these values as a compass to guide her on her life path. She makes decisions and chooses actions that are consistent with her values. She maintains her principles with conviction, especially in the face of adversity. She is confident, tenacious, determined, responsible, and conscientious. She is not easily swayed by external pressure or public opinion, but she remains open to new ideas and various perspectives. She cares for herself so that she can maintain her fortitude. She mindfully accepts all of her emotions and experiences them fully, but she does not allow unpleasant emotions to prevent her from living a valued life. She seamlessly integrates logic, emotion, and intuition. She takes risks and makes mistakes. She has some successes and some failures. She emerges from her failures with grace, humility, and newfound wisdom which she applies to future endeavors. Her self-identity is well-defined. She lives unapologetically.

Having a mental illness has nothing to do with weakness, and seeking help for a mental illness is the antithesis of frailty. Consider what people with mental illnesses must endure. On the whole, they are more vulnerable to intense negative emotions, poor self-esteem, and self-destructive behavior. They face misunderstanding, stigmatization, and discrimination on a daily basis. They deal with family and friends who “just don’t get it,” an ignorant society, and a lack of awareness about their conditions. They struggle to navigate through a healthcare system that considers their disorders trivial and their treatment optional or, in many cases, fails to consider them at all.

Those who complete treatment successfully and manage their mental illnesses adaptively are amongst the strongest people I have ever had the privilege of knowing. They own their recovery and take responsibility for staying well. They make a point of living lifestyles that are conducive to health and happiness, even in cultures that teach otherwise. Armed with effective coping skills and hard-earned insight, they pursue life in a deeper, more meaningful way. They know when they need help and they know how to get it without delay. They make use of whatever tools they have, such as therapy, psychotropic medication, exercise, spiritual practice, or meditation. They surround themselves with a positive social network and they utilize family and friends for practical and emotional support. They are able to derive meaning from their suffering, and quite often they draw upon their own experiences to help others. They are wise beyond their years, and they don’t take their hard-earned sanity for granted.

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Food, Safety, and Trust

Earlier this week, I read about a hospital program that provides medical stabilization for patients with eating disorders. The medical director of this program wrote that if a patient “refuses” meals and liquid supplements, the staff observes the patient, without intervention, for approximately 48 hours. If the patient continues to “refuse” nourishment after that point, the physician and psychologist have a discussion with the patient about using a nasogastric tube, but recommend oral feeding instead.

Disheartened to read about this hospital’s approach, I politely asked the medical director to explain the medical or psychological rationale for waiting 48 hours before providing a hospitalized, medically unstable eating disorder patient with some form of nourishment. Her response was that most patients with anorexia “are not at increased at increased medical risk by waiting one or two days to begin serious re-feeding.” Further, she wrote that it is “medically and psychologically safer” for patients to under-eat for a couple of days and then start re-feeding, when they are “fully committed to the process and trusting the treatment staff.”

I don’t have a medical degree, but I do know more than the average person about the medical complications of eating disorders. I’m not aware of any medical reason why it would be safer for a low-weight, medically-compromised anorexic patient to go without any nourishment, or without sufficient nourishment, for ANY period of time, let alone 48 hours. It is my understanding that re-feeding should begin as soon as possible. Clearly, severely malnourished patients who are at risk for re-feeding syndrome should be started on a low-calorie meal plan which is gradually increased by several hundred calories each day until they reach an appropriate caloric level for weight restoration. But still, the re-feeding process should begin immediately, right? Am I missing something here?

I do have a doctorate in psychology and a thorough understanding of eating disorders, and I am well aware of the potential psychological repercussions of this hospital’s approach. Critically ill patients with eating disorders are not “refusing” nourishment. They are suffering from a disease that renders them unable to nourish themselves or accept nourishment from others without a fight. Even if it were the case that people with anorexia “won’t” eat, rather than “can’t” eat, I would still argue that society in general, and the healthcare establishment in particular, has a moral obligation prevent people with mental illness from inflicting damage upon their bodies and brains.

For a person with a mild eating disorder who is being treated on an outpatient basis, it is unacceptable, and counter-productive to recovery, to under-eat for even one meal. Imagine, then, a severely ill, medically compromised patient who is admitted to a hospital, most likely after years of unsuccessful outpatient or residential treatment, being presented with a choice of whether, what, or how much to eat. Eating disorder patients need to be protected from their symptoms, which not only wreak havoc on their bodies, but cause unrelenting psychological anguish as well. Food is not optional for anyone. Full nutrition, as soon as possible and by whatever means necessary, cannot be presented as optional in eating disorder recovery.

The medical director of this hospital program wrote that, after approximately 48 hours of not eating or under-eating, patients can begin re-feeding “fully committed to the process and trusting the treatment staff.” I disagree with this assertion. Patients with eating disorders are rarely, if ever, “fully committed to the process” until they are much further along in their recovery. This anosognosia is a symptom of their illness, and it’s not likely to disappear after two more days of starvation. Further, “trusting the treatment staff” is not a necessary prerequisite for re-feeding. Eating disorders do not “trust” healthcare professionals because the role of healthcare professionals, at least in theory, is to annihilate eating disorders. Gaining the trust of the patient, however, is a different story. I would wonder how a patient could ever trust a staff that stood by as she starved for a couple of days. If you can’t count on a medical stabilization program to ensure full nutrition and protect you from your illness, then who can you rely upon?

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Lifestyles of the Depressed and Anxious

Despite miraculous advances in science, medicine, and technology, the rates of mental illness in the western world are higher than ever before. For instance, the rate of depression in the United States is ten times higher today than it was just two generations ago. Most mental illnesses are biologically-based and genetically-transmitted, but genes don’t change that fast, and we are biologically quite similar to our ancestors. Prior to the 20th century, human beings faced more risk and hardship on a regular basis than most of us will ever know, all without the advantage of modern science and medicine. But somehow, they were more resilient. How can this be?

Research suggests that many features of the modern lifestyle are toxic to our mental health. Most Americans have at least one, if not many, of the following issues:

• Too little sleep (less than 8 hours per night)
• Not enough exercise
• Insufficient exposure to sunlight
• Insufficient time outdoors
• Hectic, overscheduled lifestyles
• Too little “down time” to relax and unwind
• Poor eating habits (dieting, skipping breakfast, overeating, having too few fruits and vegetables, skimping on protein and dairy and carbohydrates and fats, eating too many processed foods, insufficient intake to meet one’s energy demands)
• High levels of stress
• High levels of caffeine consumption (more than 2 caffeinated beverages per day)
• Excess alcohol consumption
• Use of illegal drugs
• Over-reliance on prescription and over-the-counter medications
• Social isolation
• Underutilization of family and community supports
• Intense pressure (self-imposed and socially prescribed) to achieve and perform

Sound familiar?

Any one of these issues has the potential to trigger a mental illness in someone who is biologically vulnerable. The unfortunate reality, however, is that most Americans are dealing with several of these concerns simultaneously. No wonder we are so depressed and anxious!

Hundreds of years ago, our lifestyles were much simpler and much healthier. Our better habits were reflected in our mental health. Consider the Amish, who pride themselves on resisting societal change and maintaining their 18th century lifestyle. The Amish have very low rates of mental illness. I believe this is largely attributable to their lifestyles: they are physically active every day, they get plenty of sleep, they simplify their lives, they have low levels of stress, they eat naturally and nutritiously without dieting, they are deeply spiritual, they have a strong sense of community, and they rely upon their families, neighbors, and churches for social support.

Consider the Kaluli, an aboriginal hunter-gatherer tribe native to the highlands of New Guinea. Relatively untouched by modern society, their lifestyles closely resemble those of our ancestors. They live and work outdoors, they are physically active for most of the day, they eat naturally and bountifully from the land, they get plenty of sleep, and they rely heavily on their families and communities for support. A western anthropologist who studied the Kaluli people for nearly a decade found that clinical depression was virtually nonexistent in their tribe.

I would bet that many Amish and Kaluli people have biological predispositions for mental illnesses, but these genes are less likely to be expressed in an environment that protects and nurtures the body, mind, and spirit. We are less likely to develop body image problems if we grow up in a society without dieting and without a narrowly-defined, media-promoted, unhealthy standard of beauty. We are less likely to develop eating disorders if we live in a society in which everyone eats, effortlessly and without guilt, the types and quantities of foods that their bodies need. We are less likely to suffer from anxiety or depression if we are well-rested, well-nourished, and well-supported by our families and communities. Our children are less likely to show signs of inattention and hyperactivity if they get plenty of fresh air and outdoor exercise and have minimal exposure to television, computers, video games, and cell phones. We may discover that, if we are truly caring for ourselves, we don’t need a cup of coffee to wake up in the morning, we don’t want to go out drinking on the weekends, and most of our aches and pains will diminish without the use of Advil. We may find that we actually enjoy going to bed at 9:00 and rising with the sun, spending more time outdoors, being more physically active, and letting go of excess stress that weighs us down.

Perhaps our minds are not suited for the modern world. The evolution of our brains has not kept up with advances in science, technology, and other aspects of modern life. I am not suggesting that, in a Survivor-like twist of events, we turn back time and return to our ancestral hunter-gatherer environment. Science and technology and modern society are remarkable in many ways, and I feel fortunate to live in the twenty-first century. I am suggesting, however, that we take a critical look at the way we live our lives and examine the effects that our behaviors and lifestyles have on our mental health. We can learn a few lessons from the Kaluli and the Amish. We can place more emphasis on our own self-care and encourage our friends and family to do the same.

When I was working at a university counseling center, a colleague of mine had a client – a college freshman – who met full criteria for major depression and an anxiety disorder. This young man’s case was puzzling initially because his symptoms appeared rather suddenly after starting college and he had no family history of depression or anxiety. After a thorough evaluation, my colleague recommended a few simple behavioral changes such as improving his sleep hygiene, increasing the number of hours he slept each night, decreasing his consumption of alcohol and caffeine, and increasing his physical activity. Within two weeks of changing his habits, his symptoms had disappeared entirely and he was back to his full-functioning, high-energy self.

The moral of this story is that poor self-care not only triggers or exacerbates mental illness in those who are biologically vulnerable, but it can actually create a syndrome that appears identical to a mental illness in those without a predisposition.

Very few people fully appreciate the value of self-care. Children are taught to excel in school and sports and music and arts and various other extracurricular activities. They are taught to follow the Ten Commandments and keep their rooms clean and mind their manners and look pretty. As they grow older, they are taught to stay away from drugs and have safe sex and watch their waistlines. But who will teach them good mental hygiene? Self-care is either glossed over or ignored completely in school. Many well-intentioned parents don’t model good self-care – they are overworked, overscheduled, overtired, overmedicated, over-caffeinated, and undernourished. These parents may encourage good grades and good behavior, but they are unlikely to instill good self-care habits in their children. Most physicians overlook the role of lifestyle factors in triggering or exacerbating mental illnesses, and they use medication as the first line of treatment, even if the patient’s problem could be addressed more effectively with behavioral interventions. Many therapists do not teach their clients the importance of self-care in preventing and reducing the impact of mental illness, instead choosing to target cognitive distortions or family relations or interpersonal skills. Don’t get me wrong – these issues are important as well – but without the baseline of good nutrition, plenty of sleep and exercise, stress management, and other healthy habits, the client is likely to continue to struggle with some level of depression or anxiety.

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Fear Factor

Regardless of their diagnosis or primary presenting problem, most of the clients I see are struggling with some sort of anxiety. From an epidemiological perspective, this is not surprising. Anxiety disorders affect more than 40 million American adults in any given year and are more prevalent than any other type of psychiatric disorder.

Why are we so anxious? I would attribute it, in large part, to evolution. Anxiety is a universal emotional reaction experienced by all humans and most non-human species as well. Anxiety is a useful trait that has been shaped by natural selection.

Human beings are wired to respond to threat in a self-preserving way. When our body or brain detects danger, our sympathetic nervous system releases adrenaline and prepares the body to defend itself using one of three types of responses: fight, flight, or freeze. In response to threat, our heartbeat becomes stronger and more rapid and our breathing becomes faster and deeper in order to deliver more oxygen to muscle tissues in preparation for fighting or fleeing. Our pupils dilate to let in more light, which increases the sensitivity of our vision and helps us scan the environment for sources of danger. Digestion slows down or stops so as to conserve energy, and our mouth may become dry. Muscle tension increases in preparation for fight, flight, or freeze. All of these bodily reactions were vital in our ancestral environment. They allowed us to fight off predators to defend ourselves and our families. They facilitated us as we fled from all kinds of danger, from wild animals to brushfires to hostile natives. They made us freeze, like a deer in headlights, to aid in scanning the environment for danger, concealing ourselves, and inhibiting predators’ attack reflexes.

For tens of thousands of years, our ancestral environment was brutal. We faced life-or-death situations on a daily basis. Those of us with well-tuned fight or flight responses survived to adulthood and reproduced, passing their genes along to the next generation. Those of us with insufficient fear were less protected and tended to die sooner.

Fast forward to the 21st century. The fight-or-flight reflex is alive and well. If a car speeds towards us as we are crossing the street, we instinctually dart out of the way in a split second. When a masked stranger attacks us from behind, we make a quick jab to his stomach followed by a swift kick to his gonads, then run as fast as we can. These situations, though, are few and far between.

Advances in science, technology, and medicine have obliterated most of the threats our ancestors faced. Compared to people in previous eras, we face far fewer life-threatening encounters. And yet, we are more anxious now than ever before. Our ancestors feared storms, wooly mammoths, tidal waves, plagues, famines, droughts, and vengeful gods. What are we worried about? Our grades in school, our performance at work, our weight and physical appearance, our daughter’s loser boyfriend, public speaking, keeping up with the Jones, conflicts with our friends and partners, the rising costs of gas, swine flu, socialized medicine and Obama’s so-called “death panels.” Even more “legitimate” fears, like global warming, terrorist attacks, bankruptcy, and breast cancer, are probably less likely, less immediate, and less deadly than all our worrying makes them seem.

We do have an evolutionary excuse for this: the sympathetic nervous system tends to be all-or-nothing. It is not always modulated for varying degrees of danger. From a purely physiological standpoint, our bodies may respond the same way whether we are giving an oral presentation in school or being chased by a hungry lion.

Having some degree of anxiety is still advantageous in many ways. A bit of anxiety engenders caution, preparedness, and motivation. Mild to moderate levels of anxiety are associated with better school performance and higher occupational achievement. Anxiety protects us from engaging in dangerous activities, contracting deadly diseases, and acting in ways that may lead to social alienation. Anxiety, like most emotions and characteristics, can be positive when it is understood fully and managed mindfully.

However, the enormous number of Americans suffering from anxiety disorders suggests that something has gone awry with this natural, universal, ordinarily adaptive reflex. The problem, I think, is that in order to be adaptive, emotional responses must fit changing circumstances and challenges. In other words, anxiety is only beneficial insofar as it increases our fitness as a species in the modern world, allowing us to survive and thrive. We’ve been slow to adapt to certain evolutionarily recent threats. Our fears of ghosts, monsters, spiders, and snakes are perhaps a bit excessive. On the other hand, we could probably benefit from more fear of driving fast, cigarettes, and unprotected sex.

We are not slaves to our biology, and evolution is not destiny. The problem with biological determinism is not the biology; it’s the determinism. A number of psychological and behavioral treatments have been shown to reduce problematic anxiety. Through cognitive and behavioral techniques, we can gain insight into the workings of our bodies and minds, develop new ways of thinking, challenge our fears, acquire coping skills, and learn to live mindful, joyful, fulfilling lives that are not limited by anxiety.

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What’s That About?

“It’s about control.”

This statement has been applied to everything from OCD to eating disorders to self-injury to domestic violence. But, really, what does this statement mean?

When I hear that X is about Y, I generally interpret this statement in one of two ways: 1.) Y is a theme of X or 2.) Y is the most salient feature of X. For example, if someone says that Romeo and Juliet is about undying love, my interpretation is that undying love is a primary theme of Romeo and Juliet. Or if someone says: “My birthday is about me,” I interpret that as “I am the most important person on my birthday” in terms of attention, presents, and deciding how to celebrate.

In regards to the cliché that a certain psychological problem is about control, both of these interpretations make sense to a certain extent. Control is both a theme and a salient feature of OCD insofar as sufferers are overly preoccupied with controlling their external environment, as well as their thoughts and actions related to their particular obsession. For example, a person with OCD may spend hours scrubbing her body and cleaning her home in order to control the spread of germs and prevent herself or others from becoming ill.

Control is both a theme and a salient feature of eating disorders insofar as sufferers become preoccupied with controlling their dietary intake, exercise, and weight. Individuals with anorexia tend to be “over-controlled,” rigid, and perfectionistic not only with food but in other areas of their lives, while individuals with bulimia experience periods of “dyscontrol” of their emotions and food intake, resulting in binge /purge episodes.

Control is both a theme and a salient feature in the lives of individuals who engage in self-injurious behaviors such as cutting. Many, though not all, individuals who cut have experienced physical or sexual abuse, which results in feeling a lack of personal control over one’s life and one’s body. People who cut usually experience overwhelming emotions that they are unable to control. Some people use self-injury as an interpersonal message with an intent to control or manipulate others.

Control is both a theme and a salient feature in cycles of domestic violence. Through subtle and overt messages, abusers control and manipulate their victims. It is easy for abusers to control their victims because the victims are usually smaller and physically weaker than they are. In most cases, abusers have financial and / or emotional control over their victims. And, sadly, victims feel a devastating loss of personal control over their own lives.

I am concerned, however, that people who claim that a mental illness or psychological phenomenon is about control have an entirely different interpretation of this phrase. For most people, I think “It’s about control” translates to “it is caused by a lack of control or a need for control.” This interpretation has no empirical backing and, when espoused by treatment professionals, leads to ineffective treatment.

For instance, many therapists believe that eating disorders are “about control,” meaning that they believe that the etiology of eating disorders is rooted in a subconscious need for control. As a result of this theory, their treatment entails helping the patient gain a sense of personal control in other areas of her life, and advising her parents to “back off” of the power struggle around meals, with the assumption that eventually the patient will no longer feel the need to control her food intake.

There is no scientific basis for this theory or this treatment approach, and I have never met a person who has recovered this way. I’m sure such people exist, I’ve just never seen them. I would presume that these individuals went through years of treatment, suffered numerous medical and psychological problems, and spent many thousands of dollars before finally recovering. Recent scientific evidence suggests that eating disorders are biologically-based, genetically transmitted brain diseases that are triggered by an energy imbalance and perpetuated by malnutrition. There’s no room for “control” in this etiology.

While I’m on the subject of about, there’s another use of the word about that perplexes and frustrates me. Case in point: a very well-regarded eating disorder recovery website has the following mission statement on its homepage:

“We are dedicated to raising awareness about eating disorders… emphasizing always that eating disorders are NOT about food and weight.”

What does this mean? Surely, it cannot mean that food and weight are not themes in eating disorders. Nor can it mean that disturbances in food and weight are not a salient feature of eating disorders. By definition, individuals with eating disorders manifest disturbances in eating behavior, weight loss, or excessive preoccupation with weight. I can only assume, then, that this statement means that eating disorders are not caused by food and weight (or disturbances thereof). If this is the meaning of the mission statement, then the statement is undeniably false.

The latest scientific research tells us that eating disorders are, in fact, set into motion by disturbances in eating and weight. A person with a biological predisposition to anorexia nervosa or bulimia nervosa will not develop the illness unless he or she experiences a disturbance in eating and/or weight. Anorexia nervosa and bulimia nervosa are triggered by under-nutrition, which may initially be intentional (e.g., the decision to diet, “eat healthy,” or exercise more) or unintentional (e.g., the result of an illness, surgery, injury, medication, or another mental illness such as depression). The cycle of starvation in anorexia nervosa is maintained by malnutrition, and the illness is most severe and most deadly when the patient is underweight. The restrict/binge/purge cycle in bulimia nervosa is also self-perpetuating and is triggered or exacerbated by disturbances in eating behavior and preoccupation with weight. Full nutrition, weight restoration, cessation of restricting, bingeing, and purging behaviors, and decrease in preoccupation with weight are essential for full recovery. In conclusion, eating disorders are absolutely about food and weight. To neglect this perfectly obvious fact is to sabotage treatment.

Scientist-practitioner ranting notwithstanding, I think I do understand what that mission statement is intending to communicate. I think it is trying to convey that eating disorders are not just about food and weight; they also entail tremendous psychological suffering. I think the statement is trying to emphasize that correction of disturbances in eating and weight is not sufficient for full recovery, as psychological issues must be addressed as well. Finally, I think the statement hopes to convey that eating disorders are serious mental illnesses that bear little resemblance to typical dieting and body image woes.

While I applaud the website’s attempt to convey the aforementioned messages, I think the way the statement is worded has the potential to create a misunderstanding (or, at the very least, it doesn’t bring people closer to an accurate understanding). I’m guessing that eating disorder sufferers and their families, as well as the general public, will misinterpret the message, most likely in the manner I described. The consequences of such misinterpretation can be tragic.

We have a responsibility to people with eating disorders to provide them, and their families, with accurate information. Further, we have a responsibility to educate the public about eating disorders in order to reduce stigma, garner support, facilitate early detection, and lobby for more effective treatment. To start, let’s make sure the messages about eating disorders that we send, whether in person, in print, or on the internet, are accurate, understandable, easy to interpret, and scientifically-sound.

Isn’t it about time?

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Maudsley Is As Maudsley Does

Those who know me professionally are well aware that I am an advocate of the Maudsley Method of Family-Based Treatment and that I use this approach to treat my adolescent patients with eating disorders. What they may not know is that Maudsley principles pervade my treatment philosophy for eating disorder patients of all ages, regardless of the treatment approach I employ with them. For example:

• I always externalize the eating disorder and teach my patients to do the same.
• I firmly believe that patients do not choose eating disorders and that parents do not cause them. I make this point explicitly to patients and their families at the start of treatment and as many times as necessary throughout the course of treatment.
• I explanation the etiology of eating disorders as follows: We don’t know definitively what causes eating disorders, and for the purposes of this treatment, the cause isn’t terribly important right now. The most recent scientific research suggests that eating disorders are biologically-based, genetically-transmitted mental illnesses which are triggered by an energy imbalance (for example, through dieting) and perpetuated by malnutrition, with emotional stress (e.g., anxiety, OCD, depression) as an aggravating factor. I mention all of the common myths about the causes of eating disorders (e.g., the media, fear of growing up, need for control, overbearing parents) and dispute each one of them.
• At the start of treatment, I provide patients with psycho-education about the central role of full nutrition, weight restoration, and cessation of binge/purge behaviors in recovery.
• Whenever possible, I involve family members (parents, siblings, spouses, girlfriends, boyfriends) in the patient’s treatment to some extent. In some cases, family involvement may be as simple as providing family members with psycho-education, literature, and internet resources on eating disorders. In other cases, family members may participate in the evaluation or attend some therapy sessions with the patient. Regardless of the patient’s age, I like to empower those who live with her (parents, spouses, significant others) to provide meal support and help stop other symptoms such as excessive exercise, bingeing, and purging.
• I view family members as essential members of the treatment team who can provide nutritional, practical, and emotional support to the patient as she recovers.
• I make physical health (including full nutrition, weight restoration, elimination of purging and other unhealthy behaviors) the most immediate priority in treatment.
• I help patients re-learn how to eat properly on their own once they are physically healthy and psychologically prepared to assume this responsibility.
• I treat patients’ other disorders (e.g., depression, OCD, anxiety) and address their developmental, familial, and interpersonal issues after physical health has been achieved.

In my view, these principles are equally applicable for children, adolescents, college students, and adults. They apply when I am doing individual therapy using a CBT, DBT, ACT, or IPT approach. They apply when I am doing couple’s therapy when one partner has an eating disorder. And, of course, they apply when I am doing Maudsley Family-Based Therapy.

These principles are a central part of my professional identity. I stand behind them when I am giving a lecture, doing a presentation, conversing with colleagues, speaking to potential clients, talking about work with family and friends, or even answering the questions of acquaintances who are interested in what I do.

To date, the Maudsley approach has only been empirically-supported for adolescents with anorexia nervosa and bulimia nervosa. However, preliminary data suggest that Maudsley may be equally effective for pre-adolescent children and young adults. Regardless of what the eventual published data may say about broader applications of Maudsley, I will hold fast to these principles. At least until science or experience convinces me otherwise.

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Jagged Little Pills

More Americans than ever before are taking psychotropic medication. The number of people on antidepressants doubled between 1996 – 2006, yet the number of people seeing mental health professionals declined during that time period. Over 80% of prescriptions for psychotropic drugs are written by primary care physicians. I find these trends a little hard to swallow.

The overuse of psychotropic medication and the corresponding underutilization of behavioral and psychosocial treatments are disturbing on several levels. First, these trends are clearly driven by greed and profit. It serves the financial interests of the pharmaceutical industry and the insurance companies to minimize patient contact with healthcare professionals, even at the expense of quality of care. Pharmaceutical companies, with their numerous advertisements on television, on the internet, and in magazines, have the potential to reach a very large number of consumers.

Second, clients are not fully informed about all of their treatment options. More information is usually better than less information. The problem, however, is that most Americans don’t have the education and training to understand this information, nor should they. It is up to the professionals to use their knowledge and expertise, as well as their clinical judgment, to decide whether, when, and what medication to prescribe for a particular patient. That’s the way it should be. Remember the good old days when your doctor told YOU which medications you should take? Now, the commercials use cartoon neurotransmitters and wind-up dolls and present overly-simplified portraits of recovery from depression, while urging you to “Ask your doctor” how the drug du jour can help you. Another ad reads: “Taking an antidepressant? Still having symptoms of depression? Adding Abilify to your antidepressant may help.” The benefits are exaggerated and the serious side effects are downplayed. The ad does not tell you that psychotherapy, lifestyle changes, increased social support, improved nutrition, regular exercise, and adequate sleep are also likely to help. But hey, who has time for all of that? And when is the last time you saw a TV commercial touting the benefits of Dialectical Behavior Therapy? The result of this advertising is that patients go to a psychiatrist who quickly prescribes a medication after a brief evaluation and, in most cases, does no psychotherapy whatsoever. Even worse, the majority of patients will go to their primary care physician who, after a five or ten minute conversation, prescribes the psychotropic medication that the uninformed client saw on TV last night or the one of which she has samples left over from yesterday’s drug representative’s visit. There is usually minimal, if any, follow-up care, and many of these patients are maintained on a dosage of medication that is so low that it results in no therapeutic benefit whatsoever. Except maybe a placebo effect.

Third – and this point is closely related to my first and second points – clients are not getting adequate, quality mental health care. For many mental illnesses, such as panic disorder, bulimia nervosa, mild depression, generalized anxiety disorder, and PTSD, certain forms of psychotherapy are more effective than medication. For other mental illnesses, such as recurrent major depression, the combination of psychotherapy and medication generally produces the best outcome. In many cases, adding psychotherapy to medication treatment allows clients to take fewer medications and lower doses of medication. Clients who receive a combination of psychotherapy and medication are less likely to relapse when the medication is discontinued, compared to clients who are treated with medication alone. The benefits of good psychotherapy are long-lasting and, in some cases, curative. In contrast, medication is merely palliative, and its benefits usually fade once it is discontinued. For certain conditions, such as bipolar disorder, schizophrenia, and recurrent major depression, medication is clearly indicated as a necessary component of treatment and should be started immediately after diagnosis. Even in these cases, medication alone is often insufficient. Clients’ symptoms can be reduced even further, and their quality of life improved even more, when psychotherapy is combined with medication.

Finally, the fact that psychotropic medication is grossly over-prescribed and over-marketed seems to trivialize the experience of people who genuinely need psychiatric medication. Many times, I have raised the issue of psychiatric medication with clients whom I think can benefit from it. Many times, they have responded: “Oh, no. I don’t want to take a happy pill.” Or “No, I don’t want to use medication as a crutch.” Or “I don’t want to become dependent on something.” Or “That’s the easy way out.” I believe that our society’s nonchalance regarding psychotropic medication is directly responsible for some clients’ aversion to it. However, the fact that psychotropic medication is prescribed at the drop of a hat does not negate the reality that some people genuinely need it and some people truly benefit from it.

My own experience as a therapist has reinforced what I have learned by studying the research. My views on psychotropic medication can be summarized as follows: medication can be a very helpful adjunct to psychotherapy for clients who clearly need it. In other words, while I am by no means anti-medication, I am somewhat conservative in my approach to it. Case in point: although virtually all of my clients have a diagnosed mental illness, only half of them are taking psychotropic medication. For most clients, the first form of treatment should be psychotherapy focused on improving self-care, making lifestyle changes, acquiring coping skills, improving symptoms, and dealing with interpersonal issues. Medication may be introduced as an adjunct to therapy if the client does not make substantial improvement with therapy alone. I have seen many clients make marked improvements or recover completely without ever taking psychotropic medication. With clients for whom medication is clearly indicated (e.g., those with bipolar disorder), I will refer them to a psychiatrist immediately while also emphasizing that therapy, behavioral interventions, and self-care are important aspects of treatment as well. I don’t like my clients to take psychotropic medication prescribed by their family doctor for all of the reasons mentioned above. If a client comes to me on a psychotropic medication prescribed by their family doctor, I explain the importance of seeing a psychiatrist (e.g., they have specialized training in psychiatric illnesses and are more knowledgeable about psychotropic medication, they provide more thorough evaluations and better follow-up care than general practitioners) and I provide them with psychiatric referrals.

In order to rectify this situation, I believe that the following things must happen:

1.) Primary care physicians should not prescribe psychotropic medications. Instead, they should identify those patients who may have a mental illness and refer them to a psychologist or a psychiatrist for treatment.
2.) Psychiatrists should fully inform patients about the risks and benefits of taking medication, the risks and benefits of not taking medication, and scientifically-sound information on the effectiveness of medication. In addition, psychiatrists should inform patients about the effectiveness of various forms of psychotherapy, either in lieu of medication or in addition to medication. Psychiatrists should only prescribe medication to patients who are also in therapy.
3.) Psychologists and other therapists should be conservative in referring patients for psychiatric treatment and in recommending psychiatric medication.
4.) The pharmaceutical companies should stop advertising to consumers. They can still market themselves to physicians and mental health practitioners, since these professionals have the training and knowledge to use this information appropriately.
5.) Insurance companies should provide coverage for psychotherapy that is equal to the coverage they provide for psychotropic medication. Likewise, insurance companies should reimburse psychologists and other therapists at the same rate as psychiatrists.
6.) Every American should have access to local, affordable, quality, evidence-based psychotherapy.

Optimistic? Yes. Idealistic? Yes. Impossible? Absolutely not. It may not happen anytime soon, but for now, I can practice what I preach and apply my philosophy to my own clinical work.

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Military Suicides

When American men and women make the courageous choice to join the armed forces, they realize that they may sacrifice their lives for their country. What they may not realize is that they are now more likely to commit suicide than they are to die in military combat.

The incidence of suicide in the military has increased steadily since the Iraq war began in 2003. There were 67 suicides in 2004, followed by 85 in 2005, 102 in 2006, and 115 in 2007. The 2008 statistic – 128 suicides – is the highest we’ve seen since record keeping began in 1980. Shockingly, military suicides outnumbered combat fatalities during the month of January 2009.

A recent APA Online article entitled Uncertainty about Military Suicides Frustrates Services describes the military’s attempt to understand this devastating suicide epidemic and how they plan to address it.

I am frustrated and saddened, though not surprised, to learn about the alarmingly high rate of military suicides. A combination of circumstances has created the perfect storm for suicides in the military. Consider the following:

• Service members are usually between the ages of 18-24. Neurological changes, developmental issues, and psychosocial stressors make individuals in this age group particularly vulnerable to mental illness.

• Service members are separated from their family, friends, and natural support systems for many months at a time. These extended absences contribute to homesickness, loneliness, depression, financial strain, marital problems, and infidelity.

• Service members are exposed to horrific violence on a daily basis. Their lives are constantly in jeopardy, and many are wounded in the line of duty. They witness their friends being shot, maimed, and killed.

• Service members are fighting a protracted, poorly managed, generally unpopular war with no clear end in sight.

• Military leaders and medical personnel are insufficiently trained in identification of psychological problems.

• There is a huge stigma associated with seeking mental health treatment amongst service members. The stigma often prevents service members from seeking the care they need.

• Service members are worried, often justifiably, that seeking mental health services may have a detrimental impact on their military career.

• Service members do not have sufficient access to adequate psychological services.

• Excessive drinking is deeply engrained in military culture.

• Service members have easy access to deadly weapons.

Given these conditions, it is not at all surprising that suicide is a problem in the military.

Lieutenant Justin D’Arienzo, Psy.D., a naval psychologist, described these systemic problems in a recent issue of the APA’s Monitor on Psychology. When D’Arienzo was serving on an aircraft carrier, he was solely responsible for the mental health of 8,000 people. He quickly discovered that he did not have time to see everyone who needed his services. In comparison, the ship carried 5 physicians, 4 dentists, and 40 medical assistants. To make matters worse, military psychologists are poorly compensated in comparison to other healthcare professionals in the service. The salary for a navy psychologist is about half that of a navy physician. This scenario sends the following not-so-subtle messages: psychologists are less valuable than physicians and dentists, psychologists are not needed as much as physicians and dentists, and service members’ physical health and dental health are more important than their psychological wellbeing. None of these messages are true.

The recent increase in military suicides is just one of many factors that points to the glaring need for improved mental health care for our service members. I have a few ideas as to how to improve this situation. Let me preface this by noting that, as an optimist and an idealist, I often have ideas that are less than practical. Nonetheless, here are my thoughts:

• The military hires more psychologists so that the number of military psychologists is commensurate to the number of military physicians. This will ensure that there are enough psychologists to meet the mental health needs of all service members.

• Military psychologists are paid the same salary as military physicians. Let’s face it: money talks. Higher salaries will increase the competition for these jobs and attract the best and brightest psychologists in the field. It also sends a clear message that soldiers’ mental health is valued as much as their physical health and dental hygiene.

• Every service member is required to attend weekly therapy sessions before, during, and after deployment. If all service members are required to attend therapy as a matter of course, this will eliminate the inner conflict troubled soldiers experience when considering whether to seek help, and it will remove the stigma of seeking mental health services. Further, mandatory weekly therapy is a preventative measure – soldiers can process their emotions and learn healthy coping skills before they reach the point of major depression or full-blown PTSD. Soldiers go through mandatory physical training to ensure that they are in top shape for combat. Mandatory therapy will help the troops stay psychologically fit for duty.

• More frequent therapy (e.g., 2-3 times per week) is available for those who are having great difficulty coping or who are beginning to show signs of mental illness.

• Confidentiality is maintained in the same manner as it is for civilian therapy clients.

• The length of deployment is shortened for all service members.

• Troops who develop major depression, PTSD, or other psychiatric problems are sent home to their families for more intense treatment with no adverse effect on their military career.

• Military leaders and military medical personnel are provided with more training on how to spot mental health issues in troops.

Regardless of my political beliefs and personal views on this war, I have tremendous respect for the brave men and women of our armed forces. The troops deserve high-quality, accessible mental health care. They have risked their lives serving and protecting our country. Isn’t it about time we serve and protect them?

1. Military Suicide Rate. Chicago Tribune, May 29, 2008.
2. Army says suicides among soldiers at highest level in decades. Paula Jelinek, Boston Globe, January 30, 2009.
3. Army Official: Suicides in January ‘Terrifying.” Barbara Starr & Mike Mount, CNN.com, February 5, 2009.
4. Uncertainty about military suicides frustrates services. APA Online. July 31, 2009.
5. Pentagon: Military’s Mental Health Care Needs Help. CNN.com. June 15, 2007.
6. The Military’s War on Stigma. Sadie F. Dingfelder. APA Monitor on Psychology. June 2009.
7. Stahre et al. (2009). Binge Drinking Among US Active-Duty Military Personnel. American Journal of Preventative Medicine, Volume 36, Issue 3.