Tag psychotherapy

Parenting a Depressed Teen During the Holidays

depressedThe holiday season can be harder than other times of the year for people who are depressed. When someone is struggling with depression he feels estranged from himself and the world. Then, when that world temporarily gets even more unlike him (i.e., emphasizing cheer), his sense of estrangement can worsen. For this and other reasons, parenting a teen who is depressed during the holiday season can especially challenging.

Before I offer some tips, let me offer a very important proviso. Imagine you had a kid with significant dental pain and you wondered, “what meals should I prepare that best accommodate her condition?” That seems like a useful question, but only if your daughter is receiving, or is about to receive, professional dental care. Without the dental care, cooking interventions would probably be like re-arranging deck chairs on the Titanic. It is the same thing with depression in a teenager. The tips below are best considered and rendered within a context of a kid already getting good mental health care (e.g., an evidence based talking therapy such as cognitive-behavioral therapy or interpersonal therapy).

That said, here are seven tips to consider:

• Collaborate with your teen, and ideally your teen’s treatment provider, regarding a holiday plan (e.g., which activities to do and which to set aside). Your teen’s depression would have him bail out on most, if not all, activities and that is usually a mistake. Likewise, you may be tempted to insist on 100% participation, and that can be a mistake as well. A skilled therapist’s expert assistance can increase the odds that you’ll find the adaptive middle ground.

• Do what you do for your teen without the expectation that such will cheer her african woman's half faceup. We parent-lunatics hurt when our kid hurts, and often worse. So, it’s very natural to try to cheer up a depressed teen. However, if the primary intention is to bring about a better mood it’s easy to become frustrated and worsen the stress on our teen. Better to make the effort without the expectation of an outcome.

• Accept your teen’s moods as they come. These moods can be like the weather. Sure, you’ve laid out a nice picnic and here comes a rainstorm, and that stinks. You can rage at the weather (and that can take many, many forms) or pitch a tent, realizing that the weather is outside your control, and enjoy what is possible to enjoy.

• Resist trying to reassure your teen out of a negative thought. While such encouragement can often help someone who is not depressed, to a depressed person reassurances can sound like, “you don’t have anything to feel sad about, so stop it,” which can then cause the depressed person to become even more adamant about his negative thinking. This is another instance where your teen’s therapist can be very helpful in coaching you how to respond (e.g., “I think that’s your depression convincing you of a painful lie. I believe the reality isn’t nearly as painful as your depression’s lie); the technique of thought testing can also be very helpful here (e.g., see my parenting book or search using that term above).

• Don’t allow extended family to hassle your teen regarding his depression. Loved ones can say some pretty hurtful things in their desire to be helpful. Your teen’s therapist can help you to figure out your methods for doing this in a way that respects your teen’s privacy and independence.

teen diinterested face• Regularly let your teen know, without overdoing it, that you love her, that she is not alone and you understand that it’s terrible to be feeling what she is feeling, especially during the holidays.

• If your teen is or could be suicidal, get him in front of an expert ASAP and don’t leave him alone until you do. Consider this to be a life-or-death emergency as you certainly don’t want your baby to be one of the two million U.S. teens who attempt suicide each year.

Geez. Tough stuff huh? But, hopefully there’s a helpful tip or two here for you. Regardless, I hope you and yours have a wonderful holiday season!

 

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Elements of Quality Mental Health Treatment for Youth

billboard2 copyI find that many parents have little idea what to expect when taking their child or teen for mental health services. In my last blog, I described elements of a good mental health evaluation for a child or teen. In this entry I will describe elements of quality outpatient mental health treatment. (Please keep in mind that some of these elements may not be present in your child’s or teen’s care but s/he may still be receiving good treatment.)

√ A diagnostic impression is shared. The insurance company is usually getting this information, so you should too. More importantly, having these words allows you the opportunity to educate yourself about the condition(s).

√ The clinician has discussed how he or she arrived at the diagnostic formulation and the the primary scientific findings pertaining to such (e.g., causes, prevalence, outcomes).

√  The clinician shares specific information regarding which treatment(s) is/are   therapy etchingrecommended. This should include giving you the name of what each treatment is called; again, this allows you to educate yourself about the science behind the intervention. The clinician also does well to include, in instances when more than one intervention is recommended, which intervention is treating which problem or diagnosis; a discussion of the prognosis is also usually advisable.

√ The clinician endeavors to answer all of your questions, either at the time that you ask or later, including telling you when the available science does not allow a question to be answered well or thoroughly.

√ The clinician develops measurable treatment goals in collaboration with you and/or your child or teen. These goals need not be (and usually are not) a comprehensive listing of what will be worked on. But, they include signposts that help you to know (1) if the treatment is working and (2) when you are done.

therapy with teen√ The clinician is comfortable with, and even encourages, you and your child or teen to express differences of opinion regarding what s/he is stating or recommending.

√ The clinician follows the agreed upon treatment plan and doesn’t make changes without getting your informed consent.

√ The clinician tracks progress, keeps scheduled appointments, doesn’t take phone calls or check his or her phone during the appointment (unless you’ve agreed to an exception), meets the entire time, remains both pleasant and alert and gives you sufficient notice of any extended vacations or breaks from treatment.

√ You get the sense that the clinician cares about your child or teen and his or her success.

√ You are kept informed about progress. While the clinician may not share information that your child or teen wishes to keep confidential, s/he should keep you informed in general terms. If the treatment is behavioral in focus, it is also commonly recommended to teach you how to coach and reinforce the skills your child or teen is learning.

√ If there are problems at school, the clinician should be available to collaborate with school personnel; sometimes this may warrant attending an in-person meeting at the school.

√ The clinician may recommend things you can do to augment the work (e.g., overwhelmedread a book, attend a support group meeting).

√ The clinician is not shy about bringing up sensitive topics, including if s/he believes that your getting mental health care for yourself could be helpful.

√ Appointments are scheduled at a pace that is consistent with how the treatment is usually prescribed (something you can easily learn yourself with a little leg work).

√ While your insurance company may dictate what is covered and what isn’t, you should never get the sense that the insurance company is dictating what is diagnosed or what treatment(s) is/are being recommended.

Good luck! To find a clinician near you, click here.

What Can I Expect If I Take My Child to See a Psychologist?

upset characterA recent national study indicated that by adulthood about 90% of youth will have qualified for a mental health diagnosis at one point or another. However, only about 20% of these kids get any kind of mental health care. So, if your child is showing some distress s/he is in a huge club. But, if you’re getting him/her help for it, you are in an elite club.

Different mental health professions may go about their work in different ways. This blog entry is meant to characterize how an evidence-based psychologist might proceed. (While there are always exceptions, psychologists are the doctorally trained mental health professionals who most commonly provide talking treatments.)

The first thing the psychologist will do is an evaluation. These are the elements I believe constitute a cost-effective, evidence-based evaluation (each of these elements has been endorsed by the Pennsylvania Pediatric Mental Health Task Force):

• A family interview (who is in this interview can vary but often both birthboy umbrella pointing parents and the child of concern are included)

• An individual interview with the youth of concern

• The completion of behavior rating scales

• A review of relevant records (e.g., school records)

• A feedback session that reviews a diagnostic impression, addresses key issues (e.g., causes, prevalence, prognosis) and recommends a treatment plan

What follows are some common concerns I’ve heard from parents who are considering getting mental health care for their child.

If I take my child to see a child psychologist s/he might suffer self-esteem damage (e.g., mom thinks there is something seriously wrong with me).

boy head on handExperienced psychologists know that this is a concern and have procedures in place for helping (e.g., assessing for your child’s strengths, making the experience enjoyable). Moreover, the symptoms that are troubling your child are far more likely to be causing, or to cause, self-esteem damage than interacting with a highly trained, caring and kind adult.

I’m not comfortable signing up for a long course of treatment.

Most research-supported treatments, for most problems, are designed to be short-term. Sure, there are instances where a longer course of care is indicated. In medical pediatric practice short-term treatments are more common than longer-term treatments; the same thing is true in mental health pediatric practice.

Treatment is too expensive.

I’ve been doing this work for over 20 years. I’ve never seen an instance where aconfused child way wasn’t afforded to those with the will to be persistent. Please see this blog entry for a list of strategies. Moreover, the toll from untreated symptoms can be devastatingly higher.

I don’t want to weaken my child (e.g., encourage senseless whining, create dependency, promote externalizing responsibility).

Evidence-based psychotherapy is designed to make itself obsolete as soon as possible, to promote healing and to instill resilience. Alternatively, psychological symptoms often weaken functioning, dampen the human spirit and lower the ceiling on interpersonal, educational and vocational outcomes.

My kid doesn’t want to come in. There’s no point in doing this if s/he won’t cooperate.

black kid skateboardMost kids and teens are neutral or opposed to the idea of mental health care. Actually, if a kid is interested in counseling it suggests either that he or she is very psychologically minded and/or is in a great deal of pain. I tell parents new to my practice not to worry about this. It’s their job to get their kid to my office. It’s my job to make the time worthwhile.

The final chapter of my book Working Parents, Thriving Families, goes into much more depth on this topic, including describing what the most common evidence-based treatments entail and how to tell if your child is getting quality care. Please also see these related blog entries:

Seven Common Myths About Counseling

Signs that a Kid Needs Mental Health Services

Mental Health Concerns are Nearly Universal by Ag2 21

Ignoring Kids’ Mental Health Needs is Expensive

I’ll close by stating that I travel widely within my profession. My experience suggests that the average child psychologist is an extremely devoted and mission-driven person who really cares about kids and doing right by them. If you’d like to check this assertion out for yourself, click here.

Are Meds Alone Sufficient to Treat My Child’s Psychiatric Symptoms?

teenandmedicationMany parents wonder about the efficacy of using only medication to treat their child’s psychiatric condition. While a full treatment of this question far exceeds the scope of a blog, it’s possible to briefly summarize some important themes and issues.

Clinical work limited to an initial interview and medication therapy risks misdiagnosis.

This is an example of an evidence-based, cost effective and clinically effective, outpatient evaluation for a child’s or teen’s mental health symptoms (assuming medical causes have been ruled out): a family interview, an interview alone with the youth, the collection of parent, teacher and child behavior rating scales and a review of relevant records. This is complex business and I worry about the accuracy of a diagnostic formulation if one or more of these elements is missing. Moreover, it is possible for a child to improve on a given medication without the child actually having the disorder that the medication is supposedly treating (e.g., low doses of stimulant medication will often improve the concentration of any child, regardless of whether or not that child has ADHD. Of course, sometimes it isn’t possible to do more than a brief interview and a medication trial, but if it’s possible to add the other elements that would probably be advisable in most instances.

Treatment with medication alone is rarely indicated.medication

There are some mental health conditions in youth for which medication treatment will almost always be a part of an evidence-based treatment plan (e.g., ADHD, bipolar disorder, schizophrenia). However, the best designed research studies on these conditions almost always indicates that evidence-based talk therapies (usually behavioral treatments) significantly improves the efficacy of the medication treatment (e.g., decreasing the dosage of medication needed, speeding along the management of the symptoms, strengthening the degree of  improvement, reducing the odds of suicidality). Moreover, in the very large majority of instances, children with a psychiatric diagnosis have at least a second diagnosis as well, and many of these co-occurring conditions are either best treated with evidence-based talk therapy alone or are  better treated when evidence-based talk therapy is added to the treatment plan.

Certain diagnoses, while perhaps improved with medication treatment, may not need such if evidence-based talk therapy is tried first.

teenfamilytherapyFor example, for mild to moderate depressive disorders and anxiety disorders, cognitive-behavioral therapy or other evidence-based treatments (e.g., interpersonal therapy for adolescent depression) may sufficiently manage or heal the presenting symptoms without the need to add medication therapy to the treatment plan. While these treatments take more effort than swallowing a pill, they may be preferred by parents who wish to avoid artificially altering their child’s brain chemistry when talking treatments may do the job as well or better.

There are many instances when the science on medication treatments leaves important questions unanswered.

There are many unanswered questions about the pros and cons of providing childmedicationmedication therapy to very young children as there are regarding the long term consequences of being on the same medication and the degree to which medication treatments alter the development of a youth’s brain. If a child needs medication treatment in order to avoid significant here-and-now impairment, most would agree that such questions often need to take a back seat.  But, if a youth’s symptoms can be effectively treated either by not taking a pharmaceutical, or by taking a lower dose, that would appear to be a preferable choice in many instances.

The short-term conveniences affiliated with medication treatments should give us all pause.

I believe the best available evidence would support the position that effectively moneyandpillsdelivered talk therapies for youth spares money, aggravation and pain over the long run. However, in the short run, talk therapies may offer more hassles (e.g., additional costs and inconveniences) than medication treatments. Moreover, considering only short-term costs may create incentives for decision makers (e.g., insurance companies, clinicians with capitated insurance contracts, hectic parents) to gravitate towards treatment plans that only include medication therapy. Such factors should cause us all to pause and reflect on both the available scientific evidence and issues affiliated with longer term consequences.

A take home point is that it is usually a good idea to have a mental health professional on your child’s treatment team who is aware of the relevant science and clinical practicalities and who can help you to effectively navigate your choices. If you’re interested in speaking with a psychologist more about these matters, please click here.

Mom Arrested for Giving Her Daughter Xanax: CBT Can Help to Avoid Such Sad Stories

According to a story this week in the North Platte Telegraph, a mother in Nebraska was arrested for intent to deliver a controlled substance after she gave Xanax to her 15 year-old daughter (the story indicates that daughter later gave it to a friend). I know no more about this story than what is contained in the above link. But I find myself wondering how much each of the following factors contributed to this unfortunate arrest:

√ The pharmaceutical industry markets directly to the public. The marketing budget of this industry far exceeds the public education budget of any mental health association that tries to teach the public about how psychological pain can be understood and relieved.

√ Studies vary but between one in ten and one in four youth suffer from an anxiety disorder (e.g., this graph, from the National Institute of Mental Health, demonstrates the high rates in teenagers).

√ Between 2/3rds and 90% of these kids receive no care. And, even when they do receive care they’ve often been suffering for years first and/or the care is truncated (my blog post discussing some of these issues regarding teens can be found here).

√ Many people, including primary care physicians and teachers, do not know what cognitive behavior therapy (CBT) is or that it is the number one researched talking therapy for relieving anxiety in children and teenagers.

This author knows of not one authoritative association or legitimately published researcher who recommends that anxiety disorders be treated by medication alone, in any human, at least when the afflicted person is able and willing to take part in talking therapy. Moreover, many kids successfully treated with CBT do not need medication to help manage their anxiety-based symptoms.

Cognitive behavioral therapy, which is a time-limited intervention, involves learning a collection of strategies for manipulating emotions and thoughts. Some of these strategies involve recognizing and adjusting thoughts (i.e., the “cognitive” part of the term), while others involve adjusting behaviors (the “behavioral” part of the term). In the case of anxiety treatments there are often two phases. In the first phase the child or teen learns the cognitive and behavioral strategies for defeating anxiety. (In my practice I’ll teach anywhere between five and ten strategies depending on the youth’s problems and situation.) In the second phase the youth then deliberately puts herself or himself into those developmentally appropriate situations that tend to evoke anxiety (e.g., getting on a school bus instead of being transported to school) and uses the techniques to conquer the anxiety. The work is finished once the youth is able to defeat all such fears. Often at termination both the youth and her or his parent(s) cannot believe how far she or he has improved in a relatively short period of time.

These treatments can be delivered to a child by himself or herself (with intermittent parent sessions so that the parent(s) are in a position to coach the strategies once the treatment is over), in groups of youth or together with family members. To identify a mental health professional who might be available to deliver this treatment in your area, click here. Below I have also listed links to three related blog entries.

Affording Mental Health Care

Signs that a Kid Needs Mental Health Services

Seven Common Myths About Counseling

Signs that a Kid Needs Mental Health Services.

About 14-22% of children in the United States suffer from a diagnosable psychological disorder. Add 20% to that number if you include youth who suffer at sub clinical levels. However, only about 20% of these children get effective care. And, even when they get it they’ve often had to suffer for years first. This occurs even though the research on the effectiveness of child psychotherapies is very positive. What would we conclude about our culture if this were true of our childrens’ dental health instead of their mental health?

I’m writing this blog entry to try to review key indicators of when a child might benefit from mental health services. There are four primary areas of functioning that one can consider: relationships with adults, relationships with peers, academics and mood.

Relationships with adults: The key issue is whether the youth gets along reasonably well with adults. Of course this includes parents/parent-figures and teachers. But it also includes coaches, extended family, bosses, etc. If the youth is frequently in conflict or frequently avoidant or detached from any significant type of relationship with adults, an evaluation may be warranted.

Relationships with peers: Kids need to be able to form friendships, and get along effectively, with other kids who are doing well. For example, if a teen’s close friendships are primarily with those who often get into trouble, abuse substances, or are significantly symptomatic, a significant problem may be present. Likewise, if a child or teen is avoidant, aggressive, controlling or otherwise routinely rejected or ignored by most other youth, this is of concern.

Academics: This is one of the trickier areas to describe tightly. The central issue here is not grades, though grades consistently falling in the C and lower range would generally indicate that a problem exists (assuming that the teaching and curriculum are appropriate). The central issue here is the youth applying herself or himself when she or he does not feel like it.  Developing this psychological muscle (i.e., task persistence when internal motivation is required) is one of the most important developmental tasks of childhood. So if a child is not applying herself or himself, or experiencing significant turmoil or failure in academic pursuits, an evaluation is likely warranted.

Mood: The key issue is whether or not the youth is content. Happiness is great. Contentment is the bar however. If the child is consistently sad, angry or anxious for a significant portion of his or her waking day, this is signaling a need for professional attention. It is often the case that a parent may be confused regarding what a child or teen is thinking or feeling. Thus, problems with sleep, appetite, concentration, connectedness with the world or physical activity can be signs of a problem. (There may also be absences of experiences of joy, but more for kids with depressive disorders than anxiety disorders. )

As I write this blog, there are 42 ways that youth can be diagnosed with a mental health disorder. So, this is hardly a comprehensive post. However, if a child is getting along well with others, is doing well in school and seems content, that child may be fine. The only significant area I’ve left out is experiencing success in one or more extracurricular pursuits. While a lack of positive experiences in the latter area is not, by itself, necessarily indicative of a problem, a child who lacks for such experiences may be more vulnerable to attacks on self-esteem.

I hope you will share this blog post with those who could use it. If you would like to read about common myths about mental health services, click here. For ideas on how to afford care click here. And, finally, to find a lean-mean-healing machine in your neck of the woods, click here.

Affording Mental Health Care

This entry reviews the cost issues affiliated with mental health care.  While paying a provider for counseling can be expensive, it need not be. Some thoughts to help:

• Many health insurance policies cover some portion of the cost. Often a client is left with only a small copay. Moreover, with the signing into law of the Mental Health Parity and Addiction Equity Act, many policies have expanded their coverage of mental health services.

• Monies spent on counseling are usually considered a medical expense and so may be deductible from your taxes..

• If you have a university in your region with a graduate program in the mental health professions (e.g., clinical psychology, psychiatry, etc.), they may have an outpatient training clinic that offers services at a very low cost. In these clinics those working towards advanced degrees often provide the care under the supervision of experienced faculty. For instance, I direct such a clinic and our most common fee is $10/visit.

• Most people do not live far from a community mental health center. These centers receive public funding to support their charter. Therefore, many of them will offer services on a sliding scale or otherwise arrange for flexible payment plans. If you’re unsure where the one by you is, call up any psychologist in the yellow pages and ask.

• There are a number of charitable organizations that sponsor mental health services on a sliding or a reduced fee scale (e.g., Catholic Charities, Jewish Social Services, etc.). In all of the instances that I know of, one need not belong to the sponsoring religious group in order to get care.

• If you or a loved one suffer from a chronic medical or psychiatric problem you may qualify for support from social security. To find out more be in touch with an attorney that specializes in disability applications, your local community mental health center or your state’s mental health or disability offices.  Other programs may also be available if you cannot afford health insurance.

• Many providers may be willing to reduce their fee if you can show cause. I would not ask for this up front. But, after the evaluation is concluded, and the provider has come to know you and your circumstances, it never hurts to ask. The large majority of the thousands of mental health professionals I’ve met over the years are a mission-driven lot who care deeply about what they do. To find such a person near you, click here.

In factoring cost issues please also consider what it would be worth to be free of the problems that are having you consider getting care. What would it be worth to be free of depression, to have your child stop acting defiantly or be free of anxiety, to have your marriage healed, etc.? Imagine life with troubling mental health burdens either eliminated or controlled; then ask yourself what that would be worth?

For my post about common myths about counseling click here.

Resources for Suicide Prevention

As this month is suicide prevention month, I am guest blogging at the American Psychological Association’s Blog http://www.yourmindyourbody.com. My post regards suicide prevention in youth. Click here to read it.

I also did a live radio interview, on the same topic, for the Harrisburg, PA PBS radio station. To listen to it, click here.

Seven Common Myths About Counseling

The large majority of adults and kids who might benefit from psychotherapy do not receive it. For example 14-22% of U.S. children meet criteria for a diagnosable psychological disorder, but only about 20% of these kids get effective care. And, even when kids get effective care they usually suffer for years before getting it. Similar statistics are available for adults. This is beneath us as a culture and often yields dramatically painful and unnecessary outcomes (e.g., suicide is the third leading cause of death among people aged 15-24, depression has a higher mortality rate than cardiac disease, etc.).  This post reviews some of the common myths I’ve found that serve as barriers to understanding and healing.

If I enter therapy I might become too dependent on the therapist. Therapy will never end.

The goal of psychotherapy is to foster healthy independence, not unhealthy dependence. So, the aim of evidence-based psychotherapy is to reach measurable treatment goals as fast as possible. Indeed, the chief job of the competent therapist is to make her services obsolete.  While some problems require longer treatment, many do not.

Counseling costs too much money.

Most health insurance polices cover the lion’s portion of psychotherapy. Clients end up being out of pocket only for the part not covered by the insurance company. In addition, the costs are considered a medical expense and may be deductible from taxes. Studies also suggest that trips to a counselor can dramatically reduce trips to the medical doctor, sick days and an assortment of other expensive problems (e.g., divorce, addiction, etc.). Plus, think what it would be like to be rid of any significant psychological pains that inflict you or a loved one. What would that be worth? Finally, there are options for low fee services all across the country; for example, if your local university has a graduate program in the mental health professions they may have a low fee training clinic (the average fee in the clinic I direct is $10/visit), community mental health centers exist across the country, etc.

Only crazy people are in therapy.

This is really a bunch of nonsense. Putting aside the meaning of the word “crazy” for a moment, choosing to be in therapy is often a very rational act. It seems much more irrational to avoid therapy, because of silly myths, when therapy might be helpful in important ways. Effective therapy helps people to identify new methods for overcoming emotional pain and solving life’s problems. What is crazy about the pursuit of such learning?

People who spend significant time and resources on therapy are being self indulgent and selfish.

If effective therapy does anything, it increases a person’s freedom to love. Did you ever try to give to others when you have a sharp toothache? The same thing applies with psychological pain. Those who have been healed in counseling are in a position to be able to love others more and better. How can this be considered selfish?

I’ll get better eventually anyway.

According to studies on counseling, effective psychotherapy promotes healing and recovery. It may not be helpful to wait years for change. Even if change does come, the same problem may resurface later if the central issues have not been sufficiently resolved. Psychotherapy provides a way to confront and resolve problems at their source. It also provides tools for dealing with future problems. Moreover, a competent therapist can direct you to the evidence that supports the methods that he or she is prescribing.

Being in therapy is a sign of weakness. Strong, effective people don’t need help solving their problems.

Maybe in a Rambo movie. In the real world more vulnerability is often found in the person who fears acknowledging human limitations and faults and is unwilling to take the steps necessary to overcome them. Counseling is no panacea and not everybody is a candidate for counseling. However, those who can acknowledge the possible need for counseling may be stronger, and more secure in themselves, than those who cannot.

If I take my kid in for an evaluation, he’ll get the idea that there is something seriously wrong with him.

Experienced child therapists both know that parents are concerned about this and have developed procedures that minimize this risk (e.g., making sure to assess for your child’s and family’s strengths). Besides, a child or teen with a legitimate behavioral or emotional problem is much more likely to think that there is something wrong with him/her, and to have that reflected in others’ eyes, if she/he does not get help. Also keep in mind, as is the case in medicine, that behavioral and emotional problems are much more easily understood and resolved sooner rather than later.

If you are wondering if counseling might be of benefit to you or a loved one, why not look into it? A competent therapist will be able to evaluate whether or not counseling is advisable and, if advisable, what it might be able to accomplish and how long it might take to complete. What do you have to loose, really? (If you’d like a referral in your community, click here.)

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