Seeking the right mental health provider: How to weigh the pros and cons

 

When seeking out a mental health provider you have a lot of choices to weigh, such as:

  1. What kind of doctor do I want to see? Psychiatrist, psychologist, social worker, etc. In a previous blog I addressed this issue in depth (May 11th, 2016 issue “What are the different types of mental health providers”).
  2. Am I willing to go out of network (i.e., see a professional who does not accept my insurance)? The Washington Anxiety Center of Capitol Hill, the practice at which I am Director is “out-of-network.” What does this mean? It means we are a specialized Cognitive-behavioral practice that does not accept insurance. However, it does not mean you do not already have out-of-network benefits, where you can submit a receipt on your own and get some coverage for your care. Bottom line: are you willing to pay out of network? How does this decision weigh in terms of your pros and cons?
  3. Seeking a specialized service requires a specialized doctor. Too many times have I heard patients who have been in treatment for 10+ years because they went to see a generalized mental health provider. Only after that didn’t work, did they seek out services with a specialized doctor. There are several studies that look at the overall cost-benefit analyses of this approach and find that those who do not initially seek out the appropriate services tend to spend significantly longer in treatment, an increased financial investment (compared to if they sought out more expensive treatment initially) and more emotional suffering.
  4. What are you hoping to get out of treatment? Exploration of yourself? Family system changes? Behavioral changes in your child? Alleviation of marriage/relationship distress? Reduction in anxiety and depression? Thinking about what you would like can help with your decision making as well.

Hope this helps those of you out there feeling a little lost in this process. It’s a complicated one, but one well worth traveling.

Is your child’s behavior out of control?

Lately, in my practice, I have been seeing families with the concern that one child in their family is “out of control.” It’s a difficult thing to hear that a child’s problem is not just caused by the child, but very often the family system (e.g., how they interact with their parents, what is the reinforcement system in the family like, what their relationships are like with their siblings, school environment, etc.).

When examining behavioral problems, it important for a treating clinician to look at the family system like a function. What purpose do interactions serve? What is the function of the bad behavior? Sometimes “bad” behavior can be a manifestation of anxiety or depression, poor distress tolerance and/or emotion regulation, or is it attention-seeking?

Understanding the function of a behavior is necessary to be able to address it effectively. Once you can understand the function, you can see the “recipe” and the ingredients that will effectively change the behavior.

Losing your voice to anxiety and depression

 

What does that mean, to use your voice? It means you feel empowered. Whenever we experience anxiety or depression we can feel as though our opinion, our presence, our minds, and our souls do not matter. This happens to adults and children suffering from anxiety and depression.

Cognitive-behavioral therapy, an evidence-based treatment for anxiety and depression, employs particular components that address this issue. Cognitive restructuring identifies how our thoughts can become distorted as anxiety and depression increase in severity and frequency. We can put on our “scientist caps” on and fully examine the evidence in favor of and against these types of thoughts. We can also implement behavioral strategies that can increase our participation in pleasurable, activating activities that will assist in the improvement in our mood.

Lastly, we can utilize strategies that allow us to face our fears in a gradual, controlled manner, with can lead to a decrease in anxiety over a short amount of time (i.e., exposure).

These strategies can help us find our own voice again, a voice that isn’t driven or does not belong to anxiety or depression.

Take a look at our website http://www.washingtonanxietycenter.com. On the main page is a link to an article written about Exposure therapy and CBT strategies with a more detailed explanation.

 

Self-care during the Holidays

The holidays are a time of super stressors. How do we go about managing kids who cause sleep-deprived adults? How do we manage other family members with whom we have strained, complicated relationships? These are tough ones. There are no blanket recommendations in these categories, but it is very important to make sure that you prioritize and take care of yourself during the holidays.

What does this exactly entail?

  • Holidays are likely not the purposeful time to have serious conversations. Hard conversations = stress, holidays =stress, therefore if you choose between stress vs stress^2, the former is likely the better choice. If it is important to have a serious conversation, try and schedule it on a later date.
  • Take turns over the holidays taking kid shifts (as needed). For example, if you are tired, see if you can get a spouse or grandparent to be up with them in the morning to so you can sleep in. You are likely not to catch up on sleep, but it may feel good to treat yourself.
  • In the spirit of treating yourself, have the goal of making life simpler over the holidays(e.g., don’t feel pressured to use your best china, get paper plates..ok fancy ones if you insist).
  • Don’t let the kids dictate every minute of the day. There are two parts to this: Letting your kids dictate the day (where to go, what to do, what to eat, etc.), allows them to live in an ego-centric world (a world which revolves around themselves). Although this may be very developmentally appropriate at times, it is important for children to learn there is a world that matters outside of their own. Further, and more importantly (in the context of this blog), you want to make sure to schedule some fun  activities in for yourself.
  • Remember that as a parent, if we are taking care of our emotional, social, and physical needs, we are much better able to take care of those around us.

 

Have a great holiday season, and remember you matter and take care of yourself as best you can,

Dr. K

“Positive” psychology, when to focus on the good. Take some life lessons from your Thanksgiving table.

When I see patients in practice, even when we appear close to the end of treatment, there is an expectation that they must continue to tell me the negative things that are going on in their life. I make sure to stop them and ask, “Are you telling me that because it is really bothering you and you want to talk about it (when then, of course I do) or are you telling me because you think that may be what I want to hear? Around 90% of the time I hear, “I thought you only wanted to hear the bad.”

We have a tendency in our therapeutic process to focus on what is wrong, so we can make it better. But, what happens to the good that is already there? Does it not matter? Do we not care? Well, of course we do!!!! There is a cognitive distortion called “minimization.” That although something good has happened in our life, we ignore it, dismiss it, or minimize it because we are focused on what is not going well.

This Thanksgiving when you go around the kitchen table and give thanks, think about why you are doing that on one day of the year. I challenge you (and myself, because this is a really hard one to do), to think of 5 positive things that are going on in your life right now. I will lead by example: 1. I have a very supportive, kind, and caring husband. 2. I have two great kids who give me more love than I know what to do with in my life 3. I have the sweetest and smartest labrador rescue dogs who are my ear pieces and support systems more than they know. 4. Every day, as my late and beloved Cousin Susie reminds me, I have the beautiful world to look at and enjoy the breeze. 5. I am grateful I have my parents, who love and support me in every way they know how to.

I am making the pledge to not only give thanks on Thanksgiving, but to find a way to increase the positive in my life and not let “minimization” take over. Every day I will find 5 new things to be grateful for and I hope you take this challenge as well.

If you want to, tag #thanksgivingchallenge to let us know you are participating on social media.

Politics, Kids, and Mental Health

It’s an obvious statement to say that the current status of our political scene is heated, to say the least. In my practice, I see young children (ages 4-6) all the way through age 17 (and adults). I have found it very concerning how recently my kids have expressed worries, anxiety, and sadness not on the candidate of choice, but rather on overhearing dismal phrases of the future adults have reported. One of three basic models of anxiety and depression is based on observational learning (others are classical and operant conditioning, along with basic biology). When kids watch adults express their opinion or react a certain way, there can be a very high tendency to model/copy those phrases and behaviors. Think about the Bobo doll example (i.e., a child watches an adult hit a Bobo doll, a child enters the room alone, the child then hits the Bobo doll). If your child is hearing you, other adults, or teachers around them speak about the status of their future, your worries can become theirs, your sadness can become theirs. This process can happen quite automatically, without awareness or mal intent. At some point, kids integrate these worries as their own, and these worries can manifest themselves as clinical anxiety or depression.

As a clinical psychologist it is not my job to remark on the political scene. It is my job, however, to work to actively prevent the occurrence and recurrence of mental illness in children. Regardless of what your political stance is, try and keep in mind that you, as an adult are very influential on a child and they can model their thoughts, opinions, and concerns on yours.

 

 

Stigma and Mental Health

These past few weeks many celebrities have “come out” as having mental illness. To me, it’s a strange concept that having mental illness is still an embarrassing or shameful matter. We can state the obvious, yes, that getting out there and “spreading the word” or “spreading awareness” or giving money to research institutions may help decrease the stigma of mental illness. However, at the end of the day, despite all our efforts, we have not seen a major shift in the stigma of mental illness like we have with other movements. How did those movements get momentum? It does start at the grass roots, but it has to spread. It has to spread to others who do not have a vested interest in the topic. I ask that you do your part. Your part is not just caring about mental health. If you are on my blog, then I know you already do. Your part is to spread the word to others.

Some suggestions:

  1. Try the 22 day push-up challenge, which is a great way to spread mental health awareness.
  2. Tag on Facebook or twitter once per month #mentalhealthmatters
  3. Thank others when they open up about their mental health. It’s hard for anyone to open up about mental health, but let’s make it easier for others to share their experience!

I am giving a talk on Saturday (10/29/16) at the Mental Health Wellness Fair for Fairfax County Public Schools 11:30-12:20pm on kids, anxiety, and “failure to launch.” Hope to see you there!

https://www.fcps.edu/sites/default/files/media/pdf/ConferenceProgram2016.pdf

Recognizing OCD in your kids

Just like many misunderstand what is an actual clinical panic attack, versus the layman’s version of an anxiety attack, there are many who misunderstand the meaning of “OCD.”

Here is what you may think OCD is (what I have heard in my practice over the years)…

  1. Being a “neat freak” (e.g., cleaning your own house all the time, cleaning others houses all the time)
  2. Having a schedule and getting upset when someone or something messes it up
  3. “OCD” is just what someone’s personality is and nothing can be done to change it
  4. The need to control how “I” and/or someone else feels
  5. Being inflexible
  6. Being rigid

(and many others).

Clinically, OCD is diagnosed (according to the DSM-V) when there are the…

  1. Presence of obsessions, compulsions or both (there are usually both, but having just obsessions can happen as well).
    1. Obsessions-recurrent thoughts, images, or impulses that cause significant anxiety
    2. Compulsions-an overt behavior or covert thought to reduce anxiety caused by the obsession
  2. Obsessions and Compulsions are very time-consuming (e.g., usually take more than 1 hour per day) and cause distress in the family, school, or job environment.
  3. Symptoms are not better explained by a medication, physical condition, or another anxiety disorder that is more prevalent.

It is important that I note, that in kids, OCD can look like:

  1. Asking a lot of questions and reassurance, and no matter how much reassurance is given it is never enough
  2. Temper tantrums that are frequent and consistent around certain places, situations, activities, and/or people
  3. Repetitive behavior that may be hidden from the parents (e.g., turning a doorknob several times, re-taking steps, re-cleaning areas, etc.)
  4. Not getting required chores or homework done in a timely fashion or not done at all (very frequently, the amount of time and effort compulsions take leaves little room for activities we already have to get done).

What’s the good news here?

  1. Behavior therapy, particularly Exposure and Response (or Ritual) Prevention is a very effective treatment for OCD, for kids and adults.
  2. PMT (Parent-management training) is also an effective behavioral management system that will help reinforce good behaviors at home and extinguish OCD-like ones.

Gun violence and kids

Even among psychologists, this is a heated and highly debated topic. Rather than go into my opinion on the presence vs. absence of guns and violence or the presence or absence of mental health treatment availability and violence, I want to focus this blog on how we make our kids feel safe. Akin to acts of terrorism, gun violence has pervaded almost every aspect of our daily life. Over the past month, I have paid direct attention to the news and found at least one violent act occurring involving a gun every few days. Granted, I live in Washington, DC and it is a metropolitan area, but it does not take away from the importance of how this information is getting disseminated to our children across the nation.

During my last year of college I interned at a local news station in Washington, DC. I can remember being surprised that the most important stories broadcasted were ones of violence. When I asked several producers why we focused on the negative and not the large amount of positive items coming into the newsfeed, they reported, “it gets more ratings.” My own personal take away was that the media could develop bias to violence because violence “sells.” So, if this is the case (not ALL news media outlets are like this), we may be bound to see violent material in our news feeds in one way or another. If so, how we do handle filtering that information to our children? Here are some strategies I have found very helpful in addressing this topic with kids:

  1. Know what they are watching (as best you can); you can’t control what their friends pull up on YouTube when they are not in your own care.
  2. Maintain openness with them. You want your child to know that you are there for them to ask any questions they are concerned about.
  3. Do not try to “shovel worries/concerns under the carpet.” What does this mean? Too many times I have seen kids bring up heavy topics with their parents and their parents become so distressed they want anything but that conversation to happen. If your kid is talking about it with you, they NEED to talk to you to digest the information they are getting in a safe manner. Try and tolerate the distress you are experiencing to give them that chance.
  4. Do positive problem-solving. Try and come up with an active plan that makes your kid safe. If they feel they have a solution, they will be less likely to be caught up in worry.
  5. Let kids be kids at the same time. Of our lives, we only have around 10 years to be a kid. That’s only about 12.5% of our lives. Kids need to have fun and be silly to grow and develop. Refocus them on the fun they can have, while not being dismissive of concerns they bring forth.

 

Sleep and Kids

 

There are a lot of clinical issues that patients come in for, but rarely do I see someone just for sleep. However, sleep appears to be a rather HUGE issue in most of my patients with anxiety. A few things I discuss with parents of kids and teenagers regarding sleep getting in the way of anxiety, school, relationships and responsibilities:

  1. Eliminate naps-naps throw off our regular circadian rhythm and can disturb the quality and quantity of sleep overnight. There are exceptions to this rule (e.g., if you just had a newborn baby and they and you need naps (only for a shorter-term duration) or if you are physically ill).
  2. Make sure to go to bed by a decent time. This translates to at least before 1130 if you are a teenager. Teenagers in high school have to get up around 530-630 am. Falling asleep, not just being in bed, but actually sleeping, at 1130 only gives one between 6-7 hours, which is still under the minimal for sleep recommendations in this age range.
  3. Know the normal age range for sleep for your child:
    1. Newborns (0-3 months): Sleep range narrowed to 14-17 hours each day (previously it was 12-18)
    2. Infants (4-11 months): Sleep range widened two hours to 12-15 hours (previously it was 14-15)
    3. Toddlers (1-2 years): Sleep range widened by one hour to 11-14 hours (previously it was 12-14)
    4. Preschoolers (3-5): Sleep range widened by one hour to 10-13 hours (previously it was 11-13
    5. School age children (6-13): Sleep range widened by one hour to 9-11 hours (previously it was 10-11)
    6. Teenagers (14-17): Sleep range widened by one hour to 8-10 hours (previously it was 8.5-9.5
    7. Younger adults (18-25): Sleep range is 7-9 hours (new age category)
    8. Adults (26-64): Sleep range did not change and remains 7-9 hours
    9. Older adults (65+): Sleep range is 7-8 hours (new age category)

(information copied and pasted from the National Sleep Foundation, 2015 studies).

  1. Being tired is not an indication that you need to sleep more (i.e., more sleep won’t necessarily fix that feeling of “tiredness.”)
  2. Maintain a consistent sleep schedule for your kids as best you can.
  3. Limit access to any screens (ipad, tv, computer) at least 1 hour before bedtime (you want to mimic the signs your body naturally receives when the sun sets. If your body perceives light, it thinks it needs to wake up and become activated).

 There are many more sleep remediation points for discussion, but these are some good ones to get covered on your own.