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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.

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Rethinking Residential Treatment: Less is More

I am not a fan of residential treatment for eating disorders as it exists today. I am not aware of any scientific research suggesting that residential treatment is superior to outpatient treatment, with the exception of marketing materials from residential treatment centers (which have an obvious bias and financial incentive). We do know that hospital admissions and stints in residential treatment are poor prognostic factors – patients who remain at home and recover through outpatient treatment are more likely to recover than those who go through residential care. To be sure, the relationship between residential treatment and prognosis may be correlational rather than causal. Patients who are sent away to residential treatment generally have longer duration of illness, greater severity of illness, more psychiatric comorbidity, and a history of unsuccessful outpatient treatment.

There is one recently published randomized controlled trial of outpatient vs. residential treatment. Results of this study demonstrated that adolescents who were randomly assigned to outpatient treatment fared just as well as those who were randomly assigned to residential treatment. Given that outpatient treatment is less expensive and less disruptive to the adolescent’s life, the authors conclude that outpatient treatment is preferable.

I am a firm believer in evidence-based outpatient treatments which keep family members fully informed and actively involved whenever possible. Patients who receive treatment which prioritizes nutritional rehabilitation, weight restoration, and cessation of restricting/bingeing/purging behaviors as the essential first step, are more likely to achieve full recovery in less time. In an ideal situation, a skilled therapist can utilize the strengths and resources of the family and coach them in understanding eating disorders, refeeding their loved one, and interrupting her eating disorder behaviors. Families can also be coached in how to maintain a home environment which is conducive to recovery while their loved one participates in therapy to acquire healthy coping skills, learn how to prevent relapse, and manage any comorbid conditions. This is how the Maudsley Method of Family-Based Treatment works. At this time, the Maudsley method is the only empirically-supported treatment for adolescent anorexia nervosa, and has also been shown to be equally effective in treating adolescent bulimia nervosa. Empirical studies on the use of a modified Maudsley approach in treating young adults with eating disorders have not yet been published. However, anecdotal evidence suggests that many young adults respond favorably to a modified Maudsley approach – even those who have been ill for many years and have had numerous stays in inpatient or residential treatment. And, let’s face it: we don’t really have a good alternative treatment for young adults with anorexia nervosa.

The majority of patients who are treated with Maudsley do achieve and maintain full recovery. Simply put, Maudsley works, and there aren’t any great alternatives. Thus, Maudsley should typically be the first-line treatment, especially for adolescents with anorexia nervosa, and should commence immediately following diagnosis. That being said, Maudsley may not be appropriate in a minority of cases. For example, families who are unable to find evidence-based treatment providers near their home, families in which neither parent has the necessary time or energy due to very demanding careers or caring for other small children, families in which parents cannot agree to Maudsley and refuse to compromise or work together, families in which there is abuse or addiction, or families in which one or both parents suffers from a physical or mental illness which impairs their ability to parent their child effectively.

Despite the promise of the Maudsley Method, it is not necessarily effective or appropriate for all patients (this statement, while often cited by critics of Maudsley, is annoying and virtually meaningless because NO form of treatment for any psychological or medical illness is ever appropriate and effective for 100% of patients. This is not a weakness of a particular treatment method; this is just reality). For the aforementioned reasons, there is, and probably always will be, a need for residential treatment for eating disorders.

Residential treatment for eating disorders, as it exists today, has several benefits and several drawbacks. The benefits include:
• Supported nutrition to promote appropriate weight restoration
• Round-the-clock monitoring to prevent patients from engaging in bingeing, purging, restricting, and substance use
• Protection from self-harm and suicide
• Providing the patient with a respite from the stresses of school, work, sports, and everyday life
• Providing the family with a respite from the daily strain of caring for their loved one

The drawbacks to residential treatment, as it exists today, include:
• Prolonged separation from the family and home environment
• Prolonged absence from school, friends, extracurricular activities, and normal routines
• Exposure to other eating disorder patients, which can result in acquisition of new symptoms, solidification of identity as an “eating disorder patient,” and competitiveness with other patients about who is sicker or thinner
• Artificial environment – a “bubble” – which does not translate to real-world living
• Exposure to outdated and unproven theories about the etiology and treatment of eating disorders (e.g., blaming “family dysfunction,” search for “root causes,” exploration of supposed “underlying issues”)
• Failure to plan adequately for a smooth transition home
• Insufficient family involvement (weekly phone sessions and “family weekend” pay lip service to family involvement, but they often play the blame game, focus on presumed family dysfunction, advise parents to “back off” and not be the “food police,” and fail to educate families as to how to help their loved one recover. In essence, many family sessions send all the wrong messages and fail to send the helpful ones).
• Over-diagnosis of and over-medication for supposed comorbid disorders which are largely, if not entirely, the result of malnourishment and / or refeeding
• Attempts to use psychotherapy of any kind on patients who are not able to benefit cognitively or emotionally.

These last two points are particularly striking to me (granted, these problems occur with less-informed outpatient treatment as well). I have had many patients who were diagnosed with and medicated for severe mental illnesses such as major depression, bipolar disorder, or even borderline personality disorder, while they were underweight or re-feeding in residential treatment. In many patients, these symptoms decrease substantially or disappear altogether once the patient has reached and maintained a healthy body weight for a number of months. I have several patients who arrived at my office after years of ineffective treatment, with multiple psychiatric diagnoses, taking multiple medications. After weight restoration and maintenance along with evidence-based psychological interventions, these patients no longer required medication for any psychiatric symptoms and no longer met criteria for ANY mental disorder. Sometimes, less is more.

What many psychiatrists and other mental health professionals fail to understand is that all people who are malnourished or re-feeding, even those without eating disorders, exhibit symptoms that mimic certain mental disorders (see Minnesota Starvation Study). Diagnoses made while a patient is underweight or re-feeding are often inaccurate. Medicating a patient for a presumed mental illness which is actually the direct result of a malnourished and / or refeeding brain is at best ineffective and at worst quite harmful. Obviously, many patients with eating disorders do have genuine comorbid psychiatric issues, and clearly these need to be identified and treated. But even those patients with legitimate comorbidities may find that their other symptoms are more manageable, or require less medication, when their eating disorder is under control.

Nearly all patients in residential treatment for eating disorders are there because they are significantly malnourished or actively engaging in frequent binge/purge behaviors. These are patients with significant (though temporary) brain damage which renders them unable to process emotions, think rationally, perceive other people’s intentions, or think logically about food, weight, or body image. We know that this brain damage is reversible only after months of full nutrition, weight restoration, and abstinence from eating disorder symptoms. I understand the rationale that, since patients are in residential treatment, they should be given every possible type of treatment available from equine therapy to process groups to CBT to psychoanalysis to making pretty necklaces. I understand that the directors of residential treatment centers want to provide patients with every possible tool for recovery. But what if the patients are not yet equipped to use these tools? And what if some of these tools can be harmful? Again, this may be a case of less is more.

In my ideal world, residential treatment would retain the benefits it currently has while eliminating the drawbacks. Here’s how it would work:
• The immediate focus would be on full nutrition, full time so that patients can restore their weight as quickly as is medically safe and can break the binge/purge cycle (if applicable). This would include three meals and three snacks per day, carefully monitored. “Magic plate” would be employed, and patients would be required to eat 100% of their meals and snacks. There would be no “rewards” for eating well or “punishments” for eating too little. Eating disorder patients are punished enough by their illness, so the last thing they need is a punitive external measure. Rather, there would be no alternative other than to consume full nutrition, preferably through food, but otherwise through a supplement or nasogastric tube.
• Patients would be carefully monitored and prevented from hiding food, bingeing, or purging.
• Patients would be monitored for urges to self-injure or commit suicide and kept safe from any possible means of self-harm.
• No new diagnoses would be made and no new medications prescribed.
• No individual therapy, family therapy, or group therapy of any kind would be provided. However, a psychologist specializing in eating disorders would be available daily to provide supportive counseling for patients who request it.
• Patients would spend their days participating in relaxing, rejuvenating activities such as reading, watching movies, playing board games, getting massages, taking nature walks and practicing gentle yoga (when medically appropriate).
• Patients would be educated about the genetic and neurobiological basis of eating disorders as well as the role of under-nutrition and compulsive exercise in the development and maintenance of these illnesses. They would be provided with scientifically valid information on effective treatments for eating disorders and relapse prevention.
• Through phone conferences and/or in-person sessions, family members would be educated about the genetic and neurobiological basis of eating disorders as well as the role of under-nutrition and compulsive exercise in the development and maintenance of these illnesses. They would be provided with scientifically valid information on effective treatments for eating disorders and skills to help their loved one continue on the path to recovery at home.
• Family members would be provided with daily updates on their loved one’s progress, regardless of the patient’s age. Family members would also be encouraged to contact the treatment center at any time with questions or concerns.
• Family members and friends of the patient would be strongly encouraged to call and visit the patient whenever possible.
• A physician would set an accurate target weight range for each patient, taking into account her pediatric growth charts, weight/build history, and genetics. The target range would represent the patients’ ideal, healthiest weight, not some arbitrary minimum BMI. Research shows that the vast majority of adult patients require a BMI of at least 20 in order to achieve complete physical and mental recovery, so that would be a good starting point.

Patients would be discharged from my ideal treatment facility only after the following criteria were met:
• The patient has achieved 100% of her ideal body weight.
• The patient eats 100% of her meals and snacks with little resistance.
• The patient reports a significant decrease in urges to restrict, binge, or purge.
• The patient is not experiencing suicidal ideation or urges to self-harm.
• The patient expresses readiness for discharge and willingness to work towards recovery.
• The family has been well-educated about eating disorders and feels confident to manage their loved one’s symptoms at home.
• The patient and her family members have collaboratively developed a specific, written outpatient treatment plan. This plan includes referrals for evidence-based psychological treatment for the individual patient and her family as well as regular medical monitoring. In addition, the plan contains specific strategies for dealing with the patient’s eating disorder behaviors and for creating a pro-recovery home environment.

Although it exists only in my imagination, I would predict that a residential treatment center such as the one I described would be more effective than most currently existing treatment centers. It would also be much cheaper, since far fewer staff would be required. Granted, patients may have a longer duration of residential treatment than they do now, since the goal is 100% weight restoration, but patients would be less likely to relapse. Since this treatment center would be cheaper anyway, and patients would be less likely to require repeated admissions, the overall cost to the patient’s family and to society would be much lower.

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Recovery Timeline for Maudsley FBT

I recently conducted an informal survey of parents who had used the Maudsley Method of Family-Based Treatment to help their children recover from eating disorders. My intention was to gather some preliminary data on recovery milestones which I could share with patients and families who are just embarking on the recovery journey. Then I realized that other people may benefit from this information as well.

The following data were collected from parents of some of my patients (past and present) as well as from parents on FEAST’s caregiver forum, Around the Dinner Table. A total of 22 parents submitted responses. The patients (20 female, 2 male) ranged in age from 10 – 24 years when their family started Maudsley (mean age = 15.3 years).

The patients in my sample varied dramatically with regard to the length of their illness. Some parents reported that they began Maudsley within a month after their child’s first eating disorder symptoms appeared. Other parents had watched their child continue to suffer from the devastating effects of ED through many years of ineffective treatment and numerous hospitalizations before finally turning to Maudsley as a last resort.
Granted, this is not good science, but it is a start.

Length of time from onset of symptoms to beginning of refeeding
Mean = 18.8 months
Median = 6.25 months
Range = 1 – 132 months

Length of time from start of refeeding to weight restoration
Mean = 6.7 months
Median = 4.5 months
Range = 2 – 24 months

Length of time from weight restoration to acknowledgement of having ED
Mean = 1.1 months
Median = 0 (acknowledged having ED when he/she became weight restored)
Range = 0 – 16 months
(90 % of the sample acknowledged having ED at or before weight-restoration)

Length of time from weight restoration to developing motivation to recover
Mean = 4.6 months
Median = 0 months (motivation developed at the time of weight restoration)
Range = 0 – 24 months

Length of time from weight restoration to eating independently while maintaining weight
Mean = 7.8 months
Median = 6.5 months
Range = 0 – 36 months

Length of time from weight restoration to mood normalization
Mean = 3.3 months
Median = 2 months
Range = 0 – 12 months

Length of time from weight restoration to normalization in anxiety (return to pre-ED level)
Mean = 6.5 months
Median = 3 months
Range = 0 – 36 months

Length of time from weight-restoration to absence of body dysmorphia
Mean = 6.9 months
Median = 4 months
Range = 0 – 24 months

Clearly, more rigorous research is necessary in order to draw definitive conclusions. However, I’ve drawn some preliminary conclusions based on my data:

1.) The Maudsley Method can be effective for children, adolescents, and adults. It can be effective for both males and females.
2.) The Maudsley Method can be effective even for young adults who have been ill for 10 years or more.
3.) Most patients who are beginning Maudsley treatment have anosognosia – they do not recognize that they are ill and do not have motivation to recover. The patient does not have to “want to get better” in order for treatment to begin.
4.) The majority of patients develop insight and motivation to recover around the time that they reach a healthy body weight. For some patients, insight and motivation develop gradually after a number of months at ideal body weight.
5.) Patients generally require continued meal support for an average of 6 months after weight restoration.
6.) The manualized Maudsley approach (Lock, LeGrange, Agras, & Dare, 2001) recommends beginning to hand control of eating back to the patient when she reaches 90% of ideal body weight. This is probably too soon for most patients.
7.) The majority of patients must sustain a healthy body weight for 3-6 months before depression, anxiety, and body dysmorphia abate.

This is interesting food for thought (pun intended). I am interested in conducting a much larger survey on families that have used Maudsley. I’d like to gather enough participants and enough data points to be able to do some actual complex statistical analyses – maybe some ANOVA’s or multiple regressions. Through this study, I’d like to examine which variables contribute to recovery time. For example, what features differentiate patients who are able to eat independently at weight restoration vs. those who need continued meal support? What differentiates the patients whose psychological symptoms melt away with weight restoration vs. those who continue to struggle? Most importantly, I would like to use data from this future study to find ways in which the Maudsley method could be improved.

What questions would you like to see answered? I welcome any and all suggestions!

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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.”

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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.

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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.

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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.

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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.

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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.

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Eating Disorders: Prevention and Early Intervention Tips for Parents

There is a fair amount of internet advice for parents on how to prevent eating disorders in their children. The majority of this advice centers around teaching children about healthy eating habits, moderate exercise, positive body image, and media literacy. This is great advice for parents to follow, but it does not prevent eating disorders. It may help to prevent body dissatisfaction and dieting, but these things are not the same as an eating disorder.

Ironically, many children and adolescents who are in treatment for anorexia nervosa or bulimia nervosa report that their illness was triggered by a health or nutrition class at school, training for a sport, or a general desire to adopt the much-touted principles of “healthy eating and exercise.” Unfortunately, most of the information children receive on the benefits of “healthy eating and exercise” is really our fat-phobic society’s disguised attempt to shield our precious children from this horrible “obesity epidemic.” To make matters worse, this information is delivered to children by teachers, physicians, coaches, and parents – supposedly knowledgeable authority figures whose job is to educate, protect, and nurture them. Children who are predisposed to eating disorders are usually compliant, rule-bound, anxious, obsessive, perfectionistic, driven, and eager to please. They are virtual sponges who soak up this “healthy eating and exercise” information and follow it to the letter. The obesity hysteria terrifies them, and their obsessive, perfectionistic temperament makes them stellar dieters. This is the perfect storm for the development of an eating disorder.

I do not believe we should stop educating children about nutrition and exercise out of fear that they will develop eating disorders, much as I don’t believe we should stop educating adolescents about safe sex and contraception out of fear that they will become sexually active. More information is usually better than less, as long as the information is accurate, useful, and effective. The middle school and high school syllabi on sex education provide information which is accurate, useful, and effective (whether kids act on that information is another story). The information kids receive on “healthy eating and exercise” has not succeeded in improving their overall health, preventing eating disorders, or combating this alleged “obesity epidemic.”

I believe that, in terms of nutrition, kids should be taught about what to embrace rather than what to avoid. They should learn the importance of eating lots of fruit, vegetables, dairy products, protein, fat, and grains, and drinking plenty of water. They should be taught to enjoy their favorite snacks and deserts as well. They should not be taught about calories or the evils of sugar and fat; they should not be advised to avoid any foods, they should not learn to label foods as “good” or “bad,” and they should not be taught about the dangers of obesity or the virtue of thinness. Most importantly, I believe children should be taught about the dangers of dieting, much as they are taught about the dangers of drugs, alcohol, and unprotected sex. The dangers of dieting are grossly underrated.

Even if nutrition education is accurate, useful, and effective, it will not prevent eating disorders. That being said, what steps can parents take to prevent their children from developing eating disorders? In my opinion, it all boils down to three basic principles: 1.) accurate information, 2.) vigilance, and 3.) immediate, aggressive, effective intervention.

Accurate information
The pop-psychology literature will have you believe that if you have a healthy body image yourself, encourage healthy body image in your children, nurture positive self-esteem, and preach the importance of healthy eating habits and exercise, your child will not develop an eating disorder. This assumption is simply untrue. Parents need to know that seemingly healthy, well-adjusted children with positive body images and excellent parents develop eating disorders all the time. Good parenting does not make your child immune. It can, however, improve your child’s chances of full recovery.

If your child develops an eating disorder, let go of guilt, shame, and self-blame. While it is natural for parents to blame themselves, guilt is a hindrance to effective action. Of course you have made mistakes in parenting – everyone has! You may be an imperfect parent, but this does not mean you caused your child’s illness. Despite what you may have heard in the media, there is no reliable scientific evidence to suggest that parents cause eating disorders. If your child’s pediatrician, dietician, or therapist suggests that the eating disorder is your fault, this is an indication that he or she is not aware of recent research on the etiology of eating disorders and effective treatments. Get a second opinion. Anorexia nervosa and bulimia nervosa are biologically-based brain disorders, just like autism and schizophrenia. Although you are not to blame for causing your child’s eating disorder, it is your responsibility as a parent to ensure that she gets proper treatment. This responsibility includes protecting your child from outdated, ineffective treatments, which can often do more harm than good.

Parents also need to know that eating disorders are not limited to rich, white teenage girls. This stereotype is antiquated and dangerous, as it prevents individuals outside these demographic categories from being diagnosed and properly treated. Eating disorders strike children, adolescents, and adults; girls and boys, men and women; people of all ethnic, cultural, and economic backgrounds. Several years ago, during my training, I treated a severely underweight teenage boy with anorexia nervosa whose previous pediatrician had told him: “If you were a girl, I’d say you were anorexic.” As a result of this doctor’s failure to intervene, the patient’s condition rapidly deteriorated over the next two years, and by the time he presented in my office, he was in horrible shape.

Vigilance
Here are some concrete steps that parents can take to help prevent eating disorders. You may notice that, unlike other prevention tips you may have read, these tips center around proper nutrition and exercise. This is because all the feminist, feel-good, positive-body image talk in the world is not going to prevent eating disorders. Remember, anorexia nervosa has existed for centuries, long before thinness became fashionable. Eating disorders are triggered by an energy imbalance (consuming fewer calories than you expend) and perpetuated by malnutrition. If a child never becomes malnourished, she is extremely unlikely to develop an eating disorder.
• Make family meals a priority. As a parent, it is your job to prepare and serve nutritious foods. It is far better for a family to sit down to a balanced breakfast of cereal, milk, fruit, juice, and yogurt instead of grabbing a nutrigrain bar and running out the door.
• Closely monitor any changes in your child’s eating habits. Even seemingly “positive” dietary changes such as skipping desert, becoming vegetarian, or reducing fat intake can signal the onset of an eating disorder.
• Adopt a zero-tolerance policy towards any level of malnutrition. Do not allow your child to diet, skip meals, or cut out entire food groups. Children and teenagers need to eat three substantial, nutritious, well-balanced meals every day. Supervised, supported full nutrition is the best defense against an eating disorder.
• Be aware that eating disorders are sometimes triggered by unintentional malnourishment (for example, weight loss due to physical illness, depression, anxiety, stress, or surgery; fasting for religious purposes; side effects of a medication; intense physical exercise without a commensurate increase in nutrition). This type of malnourishment must be taken equally seriously. Dieting is not the only pathway to eating disorders (although it is the most common pathway in modern Western cultures).

Parents need to be on guard for early signs of eating disorders, especially during early adolescence, when most eating disorders develop. Since eating disorders are genetically transmitted, your child is much more vulnerable to developing an eating disorder if you or a relative has suffered from an eating disorder. Family histories of major depression and other mood disorders, anxiety disorders, OCD, and addictions are also risk factors for developing eating disorders. If you have a family history of eating disorders or other mental illnesses, you should know that your child is at greater risk for developing an eating disorder, and you should be extra vigilant.

Some early signs of eating disorders masquerade as “healthy” behaviors or extreme dedication, or can easily be dismissed as typical teenage behavior. However, parents know their kids well. Most parents recognize, long before formal diagnosis, that something is “not quite right” with their child, but they aren’t sure what is wrong or they don’t know what to do. Here are some early signs and symptoms:
• Change in eating habits. This can take many forms, including following a formal diet plan, skipping meals, eating only at certain times, refusing to eat with other people, or anxiety around food. Even seemingly positive dietary changes, such as becoming vegetarian, reducing fat intake, skipping snacks and deserts, and eating only organic foods, can be early signs of an eating disorder.
• Increased preoccupation with food: taking about food, reading diet books, collecting recipes, cooking, serving food to others, sudden interest in what other people are eating.
• Change in mood or behavior. Parents often notice dramatic changes in their child’s personality, such as irritability, anxiety, depression, moodiness, frequent crying, restlessness, withdrawal, changes in sleeping patterns, or loss of interest. Increased dedication to schoolwork, sports, or other extracurricular activities and obsessive behavior in other areas can also be early signs.
• Increase in exercise. The child may begin solo running, take up a new sport, or show increased dedication to her current sports. If she is an athlete, she may begin training excessively outside of team practices. If she is a dancer, she may begin practicing at home, signing up for more dance classes, and auditioning for every possible performance opportunity.
• Weight loss, failure to gain weight, or failure to make expected gains in height. ANY weight loss in a child or adolescent, even a few pounds, may be cause for alarm. ANY failure to grow or gain weight as expected warrants further examination.
• Loss of menstrual periods.
• Signs of binge eating (for example, large amounts of food disappearing overnight).
• Signs of purging (for example, discovering laxatives in your child’s purse or smells of vomit in her bathroom).

Immediate, Aggressive, Effective intervention
I have never heard a parent say: “I wish I had waited longer before getting my child into treatment.” Most parents whose children are in treatment for eating disorders regret not intervening sooner. In addition, many parents report that they wish they had sought out evidence-based treatment immediately, rather than continuing with ineffective treatment as their child’s health declines. If you notice any of the signs or symptoms listed above, take action immediately. Here’s how:
• Educate yourself about eating disorders and evidence-based treatment. FEAST (Families Empowered and Supporting Treatment for Eating Disorders) is an excellent resource for parents.
• Do not praise your child for her “healthy eating” habits or willpower around food. Instead, tell her that you have noticed a change in her eating habits and that you are concerned. For example: “I notice that you’re not enjoying ice cream with our family anymore. What has changed?”
• Be prepared for your child to insist that she is just trying to eat healthily, exercise more, or improve her performance in sports or dance. Many eating disorders begin this way but quickly spiral into deadly obsessions.
• Be prepared for your child to be in denial or to resist your efforts to intervene. Teenagers never say: “Mom, I think I’m developing anorexia nervosa, and I’m worried about my recent weight loss.” Denial, resistance, and lack of insight are symptoms of this disease, NOT indications that everything is OK. Don’t back down.
• Don’t waste time on “why.” When your child is developing an eating disorder, it is tempting to try to understand the reasons for it. Resist this temptation and tackle the symptoms immediately. The very foundation of ineffective eating disorder treatment begins with endless search for the “root cause” while the child continues to starve, binge, purge, and over-exercise as her physical and mental health deteriorate. A patient with an active eating disorder is generally unable to make effective use of psychotherapy because her brain is not functioning properly. Eating disorders are life-threatening illnesses with serious mental and physical risks. Think of your child’s eating disorder as a tumor. It must be removed immediately, or it will grow and metastasize. The surgeon does not need to know the reason for the tumor in order to operate and remove it. The sooner you intervene, the better your child’s chances for complete recovery. There will be plenty of time for psychological work, including an exploration of potential triggers, later on in recovery, once your child is well-nourished and physically healthy.
• As soon as you suspect a problem, take your child to the pediatrician for a complete physical exam. Unfortunately, most physicians do not have specialized training in eating disorders and are unlikely to notice an eating disorder until it is in its advanced stages. Thus, you cannot always trust your child’s pediatrician to spot a problem. I have had many patients whose physicians have completely overlooked telltale signs such as weight loss, missed menstrual periods, or failure to grow. Consider taking your child to a pediatrician or adolescent medicine physician who specializes in eating disorders. Remember, trust your parental instincts. If you think there is something wrong with your child, you are probably right. It is far better to intervene immediately and later discover that everything is fine, rather than waiting until your child is in the acute phase of a life-threatening mental illness.
• If you intervene at the first sign of an eating disorder, your child may not meet full criteria for anorexia nervosa or bulimia nervosa. Thus, she may be diagnosed with Eating Disorder Not Otherwise Specified, or she may not be diagnosed with an eating disorder at all. This does not mean that your child’s problem isn’t serious or that immediate, aggressive intervention isn’t necessary. It simply means that your child is in the beginning stages of what is likely to become a severe, life-threatening mental illness if left untreated (or improperly treated). Your child is most likely to achieve complete, lasting recovery treatment begins immediately, rather than waiting for her to develop full-syndrome anorexia nervosa or bulimia nervosa and the myriad of psychological and physical problems these illnesses entail.
• If your child has been in therapy for a while and she continues to restrict her diet, lose weight, binge, or purge, therapy is not working. In early recovery, it does not matter if your child has a good relationship with her therapist, enjoys speaking with her, or trusts her. The therapeutic relationship is only therapeutic insofar as it promotes health, wellness, and recovery. Insight, self-exploration, and rapport are useless in the wake of malnutrition. Speak with your child’s therapist about taking a different approach. If your child’s therapist refuses to talk to you, or if you are not satisfied with the results of treatment, find a different therapist.
• Seek evidence-based psychological treatment for your child and your family. Most therapists, even ones who specialize in eating disorders, are not up-to-date on the latest research and most effective treatments. I have worked with many families who have taken their child to multiple eating disorders specialists over a period of several years and seen no symptom improvement whatsoever. This is usually because the therapists were not aware of recent scientific research on eating disorders and were not using evidence-based treatments. For children and adolescents, the strongest evidence base is for Maudsley Family-Based Treatment (FBT). Maudsley FBT is a highly practical, empirically-validated treatment method which empowers the family to help the patient recover and focuses on immediate restoration of nutritional and physical health before tackling psychological issues. Research has shown that 75-90% of adolescents treated with Maudsley FBT recover within 12 months and maintain their recovery at 5-year follow-up. In contrast, traditional treatment generally takes 5-7 years and only 33% of patients achieve full recovery.
• Remember that you are an essential member of your child’s treatment team. Your child’s treatment will be most effective if you are fully informed and actively involved. Interview any potential physicians, dieticians, therapists, and psychiatrists without your child present before your child meets them. Make sure that you are comfortable with their philosophy of eating disorders and their approach to treatment. Insist on being informed about your child’s progress in treatment and ask what you can do to help her recover. If the therapist will not inform you or include you in treatment decisions, find a new therapist.
• Recognize that your child’s eating disorder is neither her fault nor her choice. Do not wait for her to “choose” recovery, because she can’t. It is your job to choose recovery for her until she is well enough to take ownership of her treatment. Try to separate the disorder from the child you know and love. She is in there somewhere, and some day, she will thank you.