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Leaving the Nest: 10 Tips for Parents

It’s back to school time! A new crop of 18-year-olds are leaving home to begin pseudo-independent lives in college. This is the time of year when my inbox is flooded with emails from other clinicians who are using professional list-serves to assemble treatment teams for their patients who are going off to universities in other cities or states.

“Looking for psychologist and psychiatrist in Atlanta for student entering freshman year at Emory. Bipolar disorder diagnosed in February 2011; has been stable on new meds since suicide attempt in June. Patient is very insightful but needs close monitoring.”

“Need treatment team in Boston for incoming freshman at Boston University with 4 year history of bulimia and major depression. Weight is normal but patient engages in binge/purge symptoms 3-4 times per week. Patient has delightful personality but is very entrenched in ED symptoms.”

“20-year-old patient with anorexia nervosa, social anxiety, and OCD just released from our day treatment program needs multidisciplinary treatment team in Chicago as she returns for her junior year at Northwestern University. Patient was discharged at 90% of ideal body weight and is compliant with meal plan. Needs nutritionist, psychologist, psychiatrist, and internist familiar with EDs.”

“23-year-old patient with major depression and alcoholism is entering graduate school at UMass Amherst and needs treatment team. Has 2 months sobriety.”

As I read vignettes such as these, I can’t help but wonder whether it is in the best interest of these vulnerable young people to be away at college. Adjectives like “compliant” and “insightful” and “delightful” seem to be inserted to justify the decision to send the patient away to school and/or to entice clinicians to take on these challenging cases. Qualifiers like “2 months sober” and “90% of ideal body weight” do nothing to quell my apprehension. Frankly, they frighten me more.

Let me be frank: a psychiatric diagnosis is a game changer. Any artificial deadlines, such as an 18th birthday or the start of the school year, are irrelevant. Psychiatric disorders are serious, potentially disabling (think major depression, which is a leading cause of lost productivity in the workplace), even deadly (think anorexia nervosa, which carries a 20% mortality rate). Individuals with psychiatric diagnoses can and do recover and go on to lead productive, fulfilling lives, but this requires prompt, effective treatment and a supportive, low-stress environment for a sustained period of time.

The transition to college presents numerous challenges to even the healthiest and most well-adjusted young people: leaving their hometown, family, and friends; living independently in a different city or state; adjusting to dorm life; navigating new peer relationships and social pressures; managing one’s time and money; choosing a career path and taking academically rigorous courses; assuming full responsibility for nutritional intake, sleep schedule, physical activity, and medical care.

Let’s face it: the typical college lifestyle does not promote physical or mental health. Late nights spent studying or partying, daytime napping, chronic sleep deprivation, erratic eating habits consisting mostly of processed snacks and caffeinated beverages in lieu of balanced meals. Most college students drink alcohol socially, and many drink to excess multiple times a week. Widespread use of illicit drugs as well as rampant abuse of black market prescription drugs as study aids (e.g. Adderall) or sleep aids (e.g., Xanax) is a mainstay of university life. Casual sex with multiple partners, often unprotected and usually under the influence of alcohol, is the norm on most campuses.

Navigating these challenges successfully requires a certain level of mental and emotional stability. Maintaining good self-care in an environment where virtually everyone else practices unhealthy habits requires a maturity and strength of character that is beyond the reach of most 18, 19, and 20 year olds.

I have treated patients before, during, and after college, and have counseled their parents throughout this process. I worked at three different university counseling centers during my doctoral training. During that time I worked with dozens of students struggling with psychiatric illnesses and gained an intimate understanding of what universities do, and don’t do, to support students with mental health problems.

Now, as a psychologist in private practice near two large universities, I treat a number of college students as well as high-school students who hope to go away to college in the near future. I also have a few patients who had attempted to go away to college in the past, but experienced a worsening of symptoms, a full-blown relapse, or in some cases life-threatening complications which rendered them unable to live independently. These are young people who have returned home to the safety of their families and are now going through treatment to repair the damage with hopes of living independently in the future.

I have developed the following professional recommendations for parents of young people with psychiatric illnesses based on these clinical experiences as well as the latest scientific research:

1.) If your child is a junior or senior in high school and hopes to go away to college in the future, begin working with her and her treatment team now to establish criteria to assess her readiness for going away to college. I recommend collaboratively establishing a written plan which includes specific, measurable criteria which the child must meet before she is permitted to leave home.

2.) If your child has had life-threatening symptoms (suicide attempt, drug/alcohol abuse, eating disorder), ensure that her condition is in full remission for at least 6 months prior to letting her go away to college. For example:
– A child with bipolar disorder should have at least 6 months of mood stability without any manic or major depressive episodes.
– A child who has attempted suicide should have a minimum of 6 months without any suicidal behaviors, gestures, or urges.
– A child with a substance abuse problem should have at least 6 months of complete sobriety.
– A child with anorexia nervosa should have at least 6 months of eating independently without restriction while maintaining 100% full weight-restoration with regular menstrual periods.
– A child with bulimia nervosa should have at least 6 months of normalized eating with complete abstinence from all binge/purge behaviors.

3.) A young person going off to college should have, at most, minimal or mild mental/emotional symptoms. For example, a child with an anxiety disorder who has occasional panic attacks, or who feels somewhat anxious at parties around new people, may be able to function well at college, but a child who has panic attacks multiple times a week or who avoids most social situations is not yet ready to go away.

4.) Ensure that your child has effective tools to manage any symptoms that may arise. This may include CBT or DBT skills to manage feelings of depression or anxiety.

5.) Work with your child and her treatment team to develop a self-care plan that includes plenty of sleep, physical activity, time management, and balanced meals and snacks at regular intervals.

6.) Do not rely upon university services (student health center or student counseling center) to provide therapy, psychiatric, or medical services for your child. University counseling centers are not equipped to manage the needs of students with major mental health issues. Most student counseling centers are over-worked, under-staffed, and underfunded. By necessity, most have limits on the number of sessions each student can attend, and most will not support parental involvement in treatment decisions or even communicate with parents at all.

7.) Prior to your child’s departure for college, establish a treatment team off-campus.
– Interview the clinicians over the phone and schedule a family meeting in person with the clinician before the school year starts, during the time you are helping your child move into the dorms. If the clinician is reluctant to talk with you over the phone or refuses to meet with you in person, this is a red flag.
– I recommend selecting a clinician who welcomes individualized, appropriate parental involvement in college students’ mental healthcare. This means working collaboratively with parents based upon the individual patient’s needs in light of her diagnosis, history, and developmental stage, irrespective of her chronological age.
– Ensure that your child signs releases of information allowing you to communicate with the clinician regarding your child’s care (law requires that persons over 18 must provide written permission for a mental health professional to release information to anyone, including parents).
– Use the initial family meeting to provide the clinician with any relevant history about your child’s condition. Written psychological evaluations or discharge summaries from previous treatment providers are very helpful in this regard.
– Work collaboratively with the new clinician and your child to establish frequency of contact, and nature of communication, between you and the new clinician. For instance, I often work out a plan wherein I call parents every two weeks, or once a month, with a general progress report on the patient, without revealing the specific content of sessions (e.g., “Mary is adjusting well to dorm life. She’s had some mild anxiety but she seems to be managing it well.” Or “Annie has been struggling with an increase in depressive symptoms over the past week. I will keep you posted and notify you right away if there is any indication of suicidality or deterioration in functioning.”) Be very clear about the type of information that will be shared between clinician and parents. It is important for the patient to establish a trusting relationship with the clinician and to feel secure that, in general, “what happens in therapy stays in therapy.” It is equally important for the parents to be reassured that they will be notified promptly if the child’s condition deteriorates.

8.) Have a safety net in place. Decide exactly what extra supports will be provided, and under what circumstances, if the child should experience an increase in symptoms while away at college. For example: an increase in symptoms lasting longer than one week may result in the child coming home for the next weekend, or perhaps a parent would travel to stay with the child in a hotel for a week or two.

9.) Have a plan B.
– Work collaboratively with your child and her new treatment team to establish what conditions would warrant a more serious intervention.
– Some situations, in my opinion, warrant a medical leave and an immediate return to the safety of home. For example, a suicide attempt or gesture, an episode of alcohol poisoning, a weight loss of more than 5 pounds (in the case of anorexia nervosa) or a recurrence of binge/purge symptoms lasting longer than a couple of weeks (in the case of bulimia).

10.) Always remember, and reiterate to your child: whatever happens is feedback, not failure.
– A medical leave of absence is not the end of the world. Nor is it permanent. It is simply an indication that your child temporarily needs more support than can be provided in the college setting. It is no different from a young person taking a leave of absence for major surgery or cancer treatment (try getting that done in the student health center!).
– Many young adults recover more swiftly from a relapse compared to the first time they were ill – the benefit of maturity and the motivation of wanting to return to college and independent living can be very helpful in this regard. If your child does well at home and recovers from the relapse, she may be able to return to school away from home the following semester or the following year.
– Depending on the circumstances and the course of your child’s illness, it is possible that the best scenario for her would be to live at home and attend college locally, or transfer to a school in-state and come home each weekend. Again, this is not the end of the world. If her recovery is robust after college, she will still have the opportunity to go away to graduate school or start the career of her dreams somewhere else.

Attending college is a privilege and a gift, not an inalienable right. It is not something that one must automatically do right after graduating from college. Living away from home, apart from one’s primary support system, to attend a faraway school is a privilege unique to American culture, and is not a prerequisite for success in any way. In most other countries, young people who do attend college (and not everyone does) do so locally while living at home until they are married.

Take your child’s psychiatric diagnosis very seriously, and do the right thing for her health. As her parent, it is not only your right but your duty to make these decisions, and you should be supported by a treatment team that empowers you to do so.

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Why Clinicians Are Resistant to Maudsley FBT

Research has shown that the Maudsley Method of Family-Based Treatment (FBT) is more effective than any other treatment for anorexia nervosa (AN) or bulimia nervosa (BN) in patients under age 18. Despite this fact, many clinicians who treat eating disorders are very resistant to using FBT to treat their patients. There are a variety of reasons for this resistance – some legitimate, some personal, some inexcusable, and some bred from ignorance.

Here are some of the most common reasons why clinicians who treat eating disorders are resistant to using FBT, along with my rebuttals to each:

1.) “I work with adults. FBT is not applicable to most adults.”

While FBT has not been adequately studied in adults, the reality is that there are no evidence-based treatments for adults with AN yet. I believe that patients over age 18 need to have loved ones fully informed about their illness and actively involved in their treatment just as much as young patients. The basic principles of FBT (with some age-appropriate modifications) are now being applied to older patients with very promising results.

As Cynthia Bulik’s recent study on Uniting Couples Against Anorexia Nervosa demonstrated, the principles of FBT can be applied very successfully to adults, using spouses or significant others for support rather than parents.

Also, there is some preliminary evidence that a modified version of FBT can be useful for college-aged patients who are temporarily living at home with parents during recovery. There may very well be a time in the not-too-distant future in which a modified form of FBT is an evidence-based treatment for adults.

2.) “Some families can’t do it.”

This statement is absolutely true – some families can’t do it. However, I believe that the true percentage of families who “can’t do it” is actually much smaller than one may think. FBT can be successful in divorced families, step-families, single-parent families, families with many children, families where both parents work full time, and families in which a parent suffers from a mental illness.

The only real contraindications for FBT in patients under18 are cases in which the patient has been physically or sexually abused by a parent, or both parents are so mentally or physically ill that they are unable to care for their children. Both of these contraindications are relatively rare, and even in these cases, one would hope that the patient would be living in a safe environment with other adults (e.g., relatives, foster parents) who could participate in FBT with the patient.

What happens too often is that parents don’t purse FBT because they aren’t aware it exists, or aren’t aware of the evidence behind it. It is also common for parents to be discouraged from doing FBT with their child because the child’s clinician (who is not really familiar with FBT or who doesn’t agree with it) tells the parent that it won’t work for their particular child for some reason.

In sum, I would estimate that maybe 10 % of families really can’t do it (I have no data to support this percentage; it is just an educated guess). The majority of families can do it if they have the proper clinical support and encouragement. The majority of parents love their children immensely and will do anything to help them recover if given the opportunity. It is up to us, the clinicians, to give families that opportunity.

3.) “Some adolescents don’t improve with FBT.”

I have no counterpoint to this one. The reality is that FBT is not effective for everyone. This is not a shortcoming unique to FBT, as there are no treatments that work for 100% of patients. I doubt that there will ever be one treatment that works for everyone in the same diagnostic category, because each individual patient is unique and has their own set of circumstances. Therefore, we must continue to research other forms of treatment and work to improve upon the existing treatments. When a patient does not improve with FBT, we must offer something else – residential treatment, day treatment, cognitive behavioral therapy – whatever is most appropriate for that particular patient and that particular family.

4.) “My training and inclination is as an individual therapist. Making the switch to working with families is intimidating. Learning FBT would be like starting from scratch.”

I don’t see it as starting from scratch. Rather, I see it as adding another (very effective) tool to your existing toolbox. You certainly don’t need to abandon individual therapy just because you’ve added a new treatment to your repertoire.

While some patients will recover fully with FBT and never need individual therapy, most patients do have co-morbid disorders or other issues which need to be addressed with individual therapy. In these cases, individual therapy comes after FBT. Many times I have transitioned to individual therapy with a patient after the patient has successfully recovered with FBT. The great thing about this approach is that the eating disorder has already been fully addressed through FBT, so you and the patient can focus all your time and energy on other things, such as depression, OCD, body image issues, perfectionism, and social difficulties.

5.) “My training is in psychodynamic therapy and relational approaches. FBT is pretty concrete and behavioral. Adopting FBT would seem to remove the very things that made me want to become a therapist in the first place – the focus on depth and the therapeutic relationship.”

FBT is more concrete and behavioral than other types of therapy, and I believe that is part of why it is so effective in treating these malignant illnesses which demand immediate behavioral management in order to save the patient’s health. That being said, the therapeutic relationship is just as essential in FBT as it is in other types of treatment. The parents and the therapist must develop trust in one another, and mutual respect is key, because the parents and therapist are allies working together against the illness on behalf of the child. It is extremely rewarding to be able to offer this kind of assistance and support to terrified, confused, guilt-stricken parents, who blossom with confidence as you educate them about the illness and empower them to do what needs to be done to help their child recover.

And the kids! It is nothing short of amazing to watch the therapeutic relationship evolve and unfold so quickly as recovery progresses. In the first few sessions, the kid typically presents as catatonically depressed, curled up in a fetal position under a blanket, sobbing quietly; or the kid reacts with extreme anger and resistance, yelling and hurling insults and dropping f-bombs before running out of the room. Entire tissue boxes are gone through in one session; stuffed animals need to be placed back on the shelves after being thrown. And within a few months, the kid is smiling, laughing, so happy to see you, chattering on about their trip to Disney World or their new boyfriend or how much they love ‘90’s music exclaiming “Wow, Dr. Ravin, it must have been so cool to be a teenager back in the ‘90’s!” The transformation is astounding.

Furthermore, there is lots of room for a tremendous amount of depth when continuing to work with the patient individually after FBT has been successfully completed. In fact, is even more feasible to go into greater depth in these cases, because the eating disorder is in remission and health-threatening behaviors have long-since been eliminated, so treatment can focus exclusively on other (often more interesting!) issues.

6.) “FBT is agnostic on etiology, and I think etiology is very important.”

Yes, FBT is agnostic with regards to etiology. In other words, the clinician states clearly at the outset of treatment that we don’t know exactly what causes eating disorders, and that it is not relevant for the purposes of this treatment. I believe this agnostic stance is one of the strengths of FBT: it does not waste time on “why” but instead focuses on “how” to help the patient recover.

I agree that etiology is very important because our ideas about etiology (for better or for worse) have a huge impact on how we treat patients. Therefore, clinicians and researchers must continue to have professional discussions about etiology amongst themselves.

My concern is not the discussion of etiology amongst professionals in the field. Rather, my concerns are 1.) When clinicians have a particular presumption about etiology which is not consistent with recent scientific evidence, 2.) When that particular presumption guides the use of treatments that are less effective, and 3.) When those presumptions about etiology cause harm to patients and their families by subtly or overtly blaming the patient or the family.

In my opinion, when clinicians discuss etiology with patients and their families, these discussions should be limited to the following points:

A.) Clarifying that neither the patient nor the family is to blame for the illness.

B.) Dispelling common myths about etiology (e.g., media, control issues, overprotective parents)

C.) Discussing the “Four P’s:” predisposing factors (e.g., genetic predisposition), precipitating factors (e.g., weight loss through dieting or illness), perpetuating factors (e.g., malnutrition has a calming and mood-elevating effect on those who are vulnerable to eating disorders), and prognostic factors (e.g., importance of early and aggressive intervention, maintenance of optimal body weight).

This is all the information patients and families need to know about etiology, because let’s be frank: this is all we really know about etiology. Anything else is just a distraction.

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When Books are Wrong

A new book on eating disorder treatment entitled When Food is Family will be published later this year. The book is written by a therapist with over 25 years of experience treating eating disorders who is also the founder and director of an eating disorder clinic.

The premise of When Food is Family is that early childhood relationships play a significant role in the development of an eating disorder. The book is based on attachment theory, which posits that “emotional support, understanding, empathy, and acceptance during a child’s development are the foundation of self-esteem and self-worth throughout life.” The author asserts that children develop eating disorders in part because they do not receive the emotional support and nurturing they need from their families, so they develop a “relationship with food” as a substitute for the intimate familial relationships they crave.

According to the online synopsis, When Food is Family “provides family members a step-by-step approach to understanding what attachment means, why connection to each other is important, how relationship breakdowns can lead to an eating disorder, how food becomes the relationship of choice, and how to go about repairing these relationships so that food (and the eating disorder) is replaced by healthy relationships within the family.”

My primary concern with this book is that it seems to set our field back about 20 years. There is no reliable scientific evidence to support the theory that disrupted attachments or dysfunctional family relationships lead to eating disorders. Nor is there any reliable evidence that treatment approaches predicated on these attachment theories help patients achieve recovery.

I absolutely agree that “emotional support, understanding, empathy, and acceptance during a child’s development are the foundation of self-esteem and self-worth throughout life.” Of course childhood environment is important in the development of self-esteem and emotional well-being. Of course “relationship breakdowns” within a family cause emotional suffering for everyone. Disrupted attachments are bad. Healthy attachments are good. But I am not aware of any evidence that disrupted attachments can lead to eating disorders.

The fact that some eating disorder patients come from dysfunctional families does not indicate that said family dysfunction caused their eating disorder. Correlation does not equal causation. Despite decades of research and millions of dollars spent on cross-sectional and longitudinal studies, researchers have not been able to identify anything that parents do, or don’t do, to cause eating disorders in their children.

The theories espoused by this book are not only unfounded and incongruent with our modern scientific understanding of eating disorders, but also potentially harmful to young patients and their families who are seeking treatment for these life-threatening illnesses.

When parents have a child with a poorly-understood, stigmatized, confusing, life-threatening illness such as anorexia nervosa or bulimia nervosa, they do not need to be told by an expert that family dysfunction is at the root of her illness. The family unit is not well-served when parents are told by an expert that they have failed to bond properly with their children, and this failure to bond has resulted in their child developing a serious illness. Parents with an anorexic or bulimic child do not need to be taught skills to develop healthy attachments with their children. They need well-informed professional support which empowers them to take aggressive action to help restore their child to health.

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Insights on Insight

Patient “insight” is a much-discussed topic in psychotherapy. Most clinicians believe that developing insight is a crucial aspect of recovery from a mental illness. Many clinicians believe that insight is a necessary prerequisite for change. There are some types of treatment, such as psychoanalysis and psychodynamic psychotherapy, which are based entirely on the development of insight. These types of treatment are predicated on the assumption that increased insight naturally leads to positive behavior change and recovery from mental illness.

These assumptions originated with Sigmund Freud, who believed that mental illness was the result of unconscious psychic conflict. He believed by bringing this conflict into the patient’s conscious awareness, it would no longer have power over the patient and the neurotic or psychotic symptoms would disappear.

The notion that exploration into one’s innermost psyche leads to healing is alluring and romantic. It makes for great novels, memoirs, and movies. The problem is, it rarely works this way in real life. While most people suffering from mental illnesses do indeed experience tremendous inner psychological conflict, there is no evidence that this inner conflict is the cause of any mental illness or that gaining insight into the conflict will promote recovery. Insight, as discussed in psychoanalytic theory or pop psychology, refers to something along the lines of “why I am the way I am” or “why I developed this mental illness.”

There are several reasons why this type of insight alone rarely leads to recovery:

1.) Contrary to popular belief, we do not know what causes most mental illnesses. We may know what factors may trigger, perpetuate, or exacerbate the illness. For example, a loss of some sort often triggers or exacerbates depression, and dieting often triggers or exacerbates an eating disorder. We may know what types of treatment are effective for certain illnesses. For example, we know that DBT is effective in treating borderline personality disorder. But any notion about causality is, at this point in time, largely speculative. So if we don’t really know what causes mental illness, insight into the supposed cause will not promote recovery.

2.) The “insights” encouraged by the therapist are often based upon antiquated theories of mental illnesses which have no empirical support (e.g., that depression is “anger turned inward”). These theories may feel good, or make intuitive sense, or seem to validate the patient’s suffering, but that doesn’t make them accurate or useful in terms of recovery.

3.) We learn and mature emotionally through experience. Thoughts and feelings follow from behavior, not the other way around. Simply knowing why you think the way you think, or why you feel the way you feel, does not change your thoughts or feelings. What does help change your thoughts and feelings is by acting opposite to them. So, for example, if you are feeling depressed and lethargic, sitting around the house all day by yourself trying to figure out why you’re depressed doesn’t make you less depressed. However, dragging yourself off the couch to go for a brisk walk outside, and then inviting some friends over to watch a funny movie, may very well lift your spirits, at least a little bit.

4.) Our neural pathways are rewired not through developing insight, but through consistent, repetitive practice of new behaviors. You will not become a good athlete by watching sports or reading about sports. Rather, you develop and hone your athletic skills by consistent practice and physical conditioning. This is why the behavioral therapies such as CBT, DBT, ACT, and FBT are so much more effective than insight-oriented therapies such as psychodynamic therapy.

5.) Some mental illnesses, such as schizophrenia, bipolar disorder, and anorexia nervosa, involve a symptom called anosognosia, which is a brain-based lack of insight. Because of abnormalities in brain function, individuals with anosognosia are unable to recognize that they are ill even when loved ones are extremely worried. For instance, a person with anorexia nervosa may feel great and perceive her body as normal and healthy, even when she is markedly underweight and clearly suffering from the physical and psychological effects of malnourishment. And an individual with bipolar mania may perceive himself as “on top of the world” and vehemently resist intervention as loved ones stand by and watch him make one self-destructive decision after another. Individuals with anosognosia should not be expected to seek treatment on their own, or to “want to recover,” because they will not have the insight to do so until they are well on their way to recovery.

The types of insights described above are relatively useless. However, there is another type of insight which results from successful treatment and is one of many markers of a psychologically healthy individual. Insight, as I conceptualize it, is best described by both the dictionary definition and the wikipedia definition. Thus, in order to successfully manage or overcome a mental illness, one must be able to discern the true nature of their mental illness and must understand cause and effect insofar as it applies to their symptoms. The following insights are extremely important to recovery:

1.) Insight into the fact that one has a mental illness. This element of insight includes acceptance of the fact that the illness is, to some extent, out of the person’s control, and cannot simply be wished away or overcome by willpower.

2.) Insight into the symptoms of one’s mental illness and how they manifest. This insight includes the ability to recognize signs and symptoms in oneself and the skills to eliminate, manage, or cope with the symptoms when they occur.

3.) Insight into the effects of following, or not following, the treatment plan and clinician’s recommendations. This insight involves understanding not only what the clinician is doing or recommending, but why she is doing or recommending it. That is, understanding the mechanism of change.

4.) Understanding how various choices one makes impact the course of one’s illness. For example, a person with a mood disorder needs to learn that by getting 8-9 hours of sleep nightly, exercising regularly, taking medication daily, and monitoring mood changes on a daily basis are essential to stabilizing moods. She will also need to learn that getting drunk on her 21st birthday, traveling across time zones for vacation without making up missed sleep, missing her medication for two days because she forgot to get refills on time, or burning the candle at both ends during final exams, will likely trigger a return of symptoms, even though “normal people” do these things all the time without a second thought. “But that sucks!” They exclaim. “That’s not fair!” They are correct on both counts.

I believe that a patient must develop all four of these insights during treatment. It is the clinician’s responsibility to assist the patient in developing these insights. It is also the clinician’s responsibility to ensure that the patient’s family members develop these insights during treatment, as it is often a parent or a spouse who will first notice the signs of relapse and encourage a return to treatment. This is especially true in disorders characterized by anosognosia.

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The Price of Assumption

Recently, there have been heated debates between clinicians and parent advocates regarding the role of environmental and family issues in eating disorders. Some people insist that family dynamics and environmental factors play a role in the development of an eating disorder. Others bristle at the possibility. Some people say “families don’t cause eating disorders, BUT…” Others fixate on the “but” and disregard everything else.

My views on this issue are complex. Thankfully, my views became much clearer to me as I was watching an episode of the E! True Hollywood Story entitled Britney Spears: The Price of Fame. Now I am able to articulate my views on this topic in a way that most people can understand.

Numerous magazine and newspaper articles have reported that Britney Spears has been diagnosed with bipolar disorder. According to unnamed “sources close to the pop star,” Spears was suffering from untreated bipolar disorder during her public meltdown and psychiatric hospitalization in 2008. While I have not treated Britney and thus cannot ethically make a diagnosis, I will say that her erratic behavior circa 2006-2008 could be explained by a bipolar diagnosis, and that the rate of bipolar disorder is thought to be quite high amongst people in the creative and performing arts.

Scientists now know that bipolar disorder is a neurobiologically-based, genetically transmitted disease. However, rather than focusing on the neurobiology or genetics of bipolar disorder, The E! True Hollywood Story explored various influences in Britney’s life that fueled her self-destructive behavior. Clearly, this type of commentary is far more interesting to the typical E! viewer than neurobiology, my own preferences notwithstanding. Several mental health professionals were interviewed and gave their opinions as to the influence of early stardom, family problems, a stage mom, excessive fame, and extreme wealth on the pop star’s behavior. Sadly, though, the viewer is led to believe that these environmental and family issues are the cause of Britney’s downfall.

Did Britney’s family or environment cause her bipolar disorder? No. Neither family nor environment can cause a brain disorder.

Did her family or environment fuel her bipolar disorder? Yes. And here’s how: Let’s say Britney had taken a different path in life, married a plumber instead of Kevin Federline and worked as a preschool teacher instead of a pop star. Let’s say she stayed in her small Louisiana hometown, never dabbled in drugs or heavy drinking, went to bed every night at a decent hour, and maintained close, age appropriate relationships with her family and good friends, making a decent living but nothing more. Would she still have developed bipolar disorder? Yes, I absolutely believe she would have (remember, most people with bipolar disorder are not pop stars, but regular people). However, her disease would have been much more easily diagnosed and treated if she had been surrounded and supported by normal, loving people who could influence her in a positive way. As it happened, her disease was certainly protracted and exacerbated by the lifestyle of a pop star, which includes late nights, insufficient sleep, excessive amounts of alcohol and drugs, and endless amounts of power and money.

If Britney’s therapist had held a family session with Lynne and Jamie Spears and Kevin Federline in attempts to “explore the family dynamics which contributed to the disorder,” that would be a complete waste of time. The elder Spears’ and Mr. Federline – the very people who are in the best position to help Britney recover – would have felt subtly blamed and marginalized. There is nothing to be gained, and everything to be lost, by approaching a brain disorder in this fashion.

The most ideal situation for Britney would be for her parents and K-Fed (and any other people close to her) to work together to provide family-based support to help her recover and to help eliminate any environmental or family factors which may be fueling her disease. It would be most helpful for her family members to be educated about bipolar disorder and understand that it is a biologically-based brain disease that she did not choose and that they did not cause. The family would also need to know that certain environmental factors, such as pregnancy and childbirth, stress, insufficient sleep, drugs and alcohol, medication non-compliance, or excessive emotional distress, can trigger episodes and exacerbate symptoms. The family would need to learn pro-active ways to help Britney manage her environment in a way that is most conducive to achieving mental and physical wellness.

In considering this example, it is important to bear in mind that people with bipolar disorder run the gamut from pop stars to professors to businessmen to truck drivers to homeless panhandlers. Families of people with bipolar disorder also run the gamut – some are amazing and supportive, others are average, and some are downright abusive. If treatment for bipolar disorder is to be successful, the clinician must perform a thorough evaluation of the patient and family, and the information gleaned from that assessment should be used to guide treatment decisions. A good clinician would not presume that the family of a person with bipolar disorder is dysfunctional or abusive, or that family dynamics caused or contributed to the development of the disorder. Similarly, a good clinician would not presume that the family is healthy or that there is nothing the family needs to change. Quite simply, a good clinician would not assume anything – she would simply perform an assessment and tailor her approach to the strengths, limitations, and realities of that particular patient and family, in line with the most recent evidence-based research.

Eating disorders are also neurobiologically-based, genetically transmitted diseases which patients don’t choose and parents don’t cause. Family issues and environment certainly can fuel eating disorders by encouraging dieting or glorifying thinness, by making diagnosis more difficult or treatment less accessible, or by making recovery harder than it needs to be.

All eating disorder patients have a biological brain disease which most likely would have arisen, at some point in time and to some degree, regardless of family or environment. Some patients have family or environmental issues which are fueling their disorder, and some do not. If such familial or environmental issues exist, they usually become quite obvious if you do a thorough assessment. These family or environmental issues will need to be addressed in treatment, not because they caused the eating disorder, but because they can trigger or exacerbate symptoms and interfere with full recovery.

But if there are no obvious familial or environmental issues fueling the disorder, please don’t waste time searching for them. You aren’t doing the patient or the family any good by “being curious,” or “just exploring.” You are simply satisfying your own voyeuristic drive, as I fulfilled mine by watching the E! True Hollywood Story on Britney Spears.

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Blame it on the Brain

There is much debate amongst mental health professionals as to whether mental illnesses should be called “brain disorders.” A large part of the disagreement, as I see it, comes from a lack of consensus as to the meaning of the term “brain disorder.”

I conceptualize a brain disorder as a disease or disorder that originates in the brain and influences mood, thinking, learning, and/or behavior. By my definition, all disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are brain disorders, including autism, ADHD, major depression, bipolar disorder, OCD, anorexia nervosa, bulimia nervosa, reactive attachment disorder, Alzheimers, and schizophrenia.

To me, “brain disorder” does NOT mean:
• Environment does not play a role in its development
• Environment does not play a role in recovery
• It is 100% biologically based
• It is 100% genetically inherited
• It can only be treated by physician or with a pill
• Psychological interventions won’t help
• The patient can’t do anything to influence the outcome

None of the above is true for ANY brain disorder, whether we’re talking about one that is commonly accepted as “biologically based” or not. In fact, I don’t know of any physical disease or medical condition in which any of the above is true.

Some people in my field are willing to apply the term “brain disorder” to some illnesses which are widely accepted to have a neurobiological basis (e.g., schizophrenia, autism, Alzheimers) but adamantly resist using this term to describe eating disorders, depression, or anxiety disorders, which they perceive to be something else. The underlying assumptions here, which few people would openly admit, are that some mental disorders are legitimate diseases whereas others are choices or responses to the environment; some mental illnesses are serious and deserve to be treated (and funded by insurance) whereas others are the patient’s or the family’s fault, so treatment is optional.

Clinicians who oppose the use of the term “brain disorder” to describe certain mental illnesses typically fall into one or more of the following categories:
• They don’t have a strong science background
• They lack basic knowledge of biology and genetics
• They suffer from (or have suffered from) the mental disorder in question and are personally offended by the term because they believe it invalidates their personal experience
• They feel that their professional identity, the work they have done for many years, is threatened by acknowledgment of the neurobiological basis of mental illness
• They believe that family dynamics or socio-cultural forces are the root cause of mental disorders, and that changing family dynamics or socio-cultural forces will cure or prevent mental disorders.

My clinical work is grounded in the knowledge that all mental illnesses are brain disorders. I believe my patients benefit from knowing that they have a neurobiologically-based, genetically inherited illness which they did not choose and their family did not cause. In order to get well, they must have a profound appreciation of their unique vulnerabilities and how to make healthful choices in order to keep themselves well. It is important for me, as a psychologist, to understand how the brain works – the mind-body-behavior connection – and it is important for me to educate my patients and their families about these issues as well.

It’s a two-way street – brain function affects thoughts, emotions, and behavior; in turn, psychological and behavioral interventions change brain function. The fact that mental illnesses are brain-based does not necessarily mean that medication is required. Research has shown that, for many brain disorders, certain types of psychotherapy are more effective than medication (e.g., mild or moderate depression, panic disorder, social anxiety disorder, anorexia nervosa). For other brain disorders, a combination of psychotherapy and medication produces better outcomes than either treatment alone (e.g., severe major depression, OCD). Less than half of my current patients are taking any psychotropic medication. Many of my patients recover fully without medication, and those who do need medication can often take fewer medications and/or lower doses once they have had good psychological intervention.

One of my college-aged patients who suffers from severe depression and anxiety recently shared the following insight, which beautifully captures the clinical utility of the “brain disorder” concept:

“With my last therapist, we just talked about what went wrong in my family that made me so screwed up. We spent the whole summer trying to figure out why I’m depressed, and it didn’t make me any better. My relationship with my parents just got worse – I got angrier at them and they felt guilty. Now I know I have a brain disorder and I know how to treat it. I come to therapy, I take my meds, and I’m OK. It works.”

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Why Psychodynamic Therapy is Harmful for Eating Disorder Patients

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

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

2.) It confuses symptoms with causes.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Time after Time

“I don’t have time.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Pride and Prejudice

“It is never too late to give up your prejudices…No way of thinking or doing, however ancient, can be trusted without proof. What everybody echoes or in silence passes by as true today may turn out to be falsehood tomorrow, mere smoke of opinion.”

– Henry David Thoreau, Walden

Last weekend, I attended the annual National Eating Disorders Association conference in New York City. It was a fantastic conference and an exhilarating experience, a whirlwind of thinking and conversing and listening and networking.

That said, I attended a few lectures that made me cringe and perhaps set the field back a few years. One well-known psychologist and author stated in her lecture that there’s a false dichotomy between research and practice, because all clinicians are, ipso facto, researchers. She went on to explain to the clinicians in the room that that if you work with eating disorder patients and you contemplate eating disorder issues, then you are a researcher.

I think, therefore I am…a researcher?

And therein lies the rub. Working with eating disorder patients and thinking about them does not make you a researcher anymore than watching MSNBC and contemplating the mid-term election makes you a political scientist.

Historically, a major problem within the field of eating disorders is that etiological theories were formed, and treatment approaches created, based upon clinicians’ casual observation and reflection. Hilde Bruch, MD, who wrote the highly influential book The Golden Cage (1978), based her theories on her observation and treatment of the anorexic patients in her practice. Bruch concluded that anorexia nervosa occurs almost exclusively in upper-class white families (because those were the families, residing in her primarily Caucasian neighborhood, who could afford to enter treatment with her), that dysfunctional patterns of family interaction are key in the etiology of anorexia nervosa (because she observed strained and tense relationships between her severely ill patients and their worried parents) and that anorexia represents a misguided attempt at forming an identity and asserting some control over an otherwise uncontrollable life (based upon the self-reports of malnourished patients suffering from a brain disease).

This book was immensely popular amongst clinicians and the general public, as it was the first book to attempt to explain anorexia nervosa, and these theories became professional dogma. Bruch’s ideas spread like wildfire, and it would be many years before scientific research would be published to counter her claims. And to this day, more than three decades later, many clinicians, anorexics, and their families still hold these beliefs.

We are, in general, resistant to change. People have a very hard time letting go of long-held beliefs, which may explain why societal change tends to happen incrementally over generations. Many clinicians have so much pride in the work they have done in the past, and so much prejudice against new ideas which are diametrically opposed to their own, that they vigorously defend the theories they have held forever even when all reliable evidence points to the contrary. They seek to assimilate new information into their preexisting beliefs (for example, a racist person may boast about having one black friend, claiming that his buddy is “not like most black people”) rather than abandoning their old beliefs once it becomes clear that they are flawed. To quote the 17th century philosopher John Locke: “New opinions are always suspected, and usually opposed, without any other reason but because they are not already common.”

It is essential, therefore, that the most recent scientific research on the etiology and effective treatment of eating disorders is featured prominently and unapologetically at local, national, and global events aimed professionals, patients, and families in the eating disorder world. The new message cannot be muted or diluted with antiquated theories or treatments under the politically-correct assumption that all ideas are equally valid. As it is, big-name wealthy treatment centers get the most publicity, most likely because of their massive donations to eating disorder organizations who feature them prominently in exhibit halls at conferences. People are so easily swayed by catch phrases and neat giveaways and glossy brochures featuring impossibly happy eating disordered teenagers riding horses and finger painting. But these centers do not necessarily offer the most effective treatments. If we want our field to make progress, if we truly want to save more lives and rescue more sufferers from the agony of this illness, money cannot trump science.

One of the most promising statements I heard all weekend was this, from a psychologist who is the director of an eating disorders treatment program:

“It is no longer acceptable, in 2010, for clinicians to practice a certain way simply because they have been practicing that way for years.”

My friend Carrie Arnold and I gave a standing ovation to that one and clapped until our hands hurt.

We invite you to join us in doing the same.

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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.