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.
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.
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.
- Try the 22 day push-up challenge, which is a great way to spread mental health awareness.
- Tag on Facebook or twitter once per month #mentalhealthmatters
- 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!
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)…
- Being a “neat freak” (e.g., cleaning your own house all the time, cleaning others houses all the time)
- Having a schedule and getting upset when someone or something messes it up
- “OCD” is just what someone’s personality is and nothing can be done to change it
- The need to control how “I” and/or someone else feels
- Being inflexible
- Being rigid
(and many others).
Clinically, OCD is diagnosed (according to the DSM-V) when there are the…
- Presence of obsessions, compulsions or both (there are usually both, but having just obsessions can happen as well).
- Obsessions-recurrent thoughts, images, or impulses that cause significant anxiety
- Compulsions-an overt behavior or covert thought to reduce anxiety caused by the obsession
- 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.
- 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:
- Asking a lot of questions and reassurance, and no matter how much reassurance is given it is never enough
- Temper tantrums that are frequent and consistent around certain places, situations, activities, and/or people
- Repetitive behavior that may be hidden from the parents (e.g., turning a doorknob several times, re-taking steps, re-cleaning areas, etc.)
- 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?
- Behavior therapy, particularly Exposure and Response (or Ritual) Prevention is a very effective treatment for OCD, for kids and adults.
- PMT (Parent-management training) is also an effective behavioral management system that will help reinforce good behaviors at home and extinguish OCD-like ones.
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:
- 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.
- Maintain openness with them. You want your child to know that you are there for them to ask any questions they are concerned about.
- 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.
- 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.
- 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.
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:
- 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).
- 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.
- Know the normal age range for sleep for your child:
- Newborns (0-3 months): Sleep range narrowed to 14-17 hours each day (previously it was 12-18)
- Infants (4-11 months): Sleep range widened two hours to 12-15 hours (previously it was 14-15)
- Toddlers (1-2 years): Sleep range widened by one hour to 11-14 hours (previously it was 12-14)
- Preschoolers (3-5): Sleep range widened by one hour to 10-13 hours (previously it was 11-13
- School age children (6-13): Sleep range widened by one hour to 9-11 hours (previously it was 10-11)
- Teenagers (14-17): Sleep range widened by one hour to 8-10 hours (previously it was 8.5-9.5
- Younger adults (18-25): Sleep range is 7-9 hours (new age category)
- Adults (26-64): Sleep range did not change and remains 7-9 hours
- Older adults (65+): Sleep range is 7-8 hours (new age category)
(information copied and pasted from the National Sleep Foundation, 2015 studies).
- Being tired is not an indication that you need to sleep more (i.e., more sleep won’t necessarily fix that feeling of “tiredness.”)
- Maintain a consistent sleep schedule for your kids as best you can.
- 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.
Recently, I have taken the plunge and have opened my own clinical practice. Now, I get to practice the skill of tolerating uncertainty, the same set of skills I practice with my patients. Tolerating uncertainty is a very difficult topic to discuss and address in session and it runs commonly across all the anxiety disorders.
How do we go about tolerating uncertainty? In general, I address that while we think we have “control” over our life, we have mostly (95% or more) reactionary lives. If you think about it, there are few instances in which we consciously think about what decision to make, how to react, or what to do. We mostly just react in the moment, but somehow we have a perception that our initial reactions are always within our control. When I have patients confronting this difficult issue, I tell them to examine 5 consecutive days of their life and see the percentage of decisions and reactions they had in which they consciously chose to react or chose a certain path. The numbers usually come back around 1-5% (that fall within conscious or purposeful decision-making).
We also believe that somehow if we are worried or concerned about the things that make us feel anxious, that somehow reduces the chances of the bad outcome happening. Logically, we can recognize that worrying about something (while non-productive) does nothing to prevent a bad outcome from happening, but it can feel much better to feel like you are doing something, rather than just accepting an uncertain fate. Take a look at your life this week and look at all the things you could be worrying about (e.g., your child’s health, being in a natural disaster, etc.) that you are not. Your brain can start to get practice recognizing your “Achilles heel” (that is, where your anxiety resides), and increasing the skills you already have in place managing other potentially anxiety-laden areas.
Also, in case anyone is interested. My new practice is the “Washington Anxiety Center of Capitol Hill” at www.washingtonanxietycenter.com. Come by and visit us!
Bullying has been an especially frequent topic in our practice and in the media. How can we identify when someone is being bullied? Is it when someone disagrees with you? Is it when someone makes aggressive physical contact?
Bullying is the same whether we are 30 years old, or whether we are an elementary-aged school child. Let’s examine how to identify when you are being bullied.
- Is the child, adolescent or adult speaking negatively behind your back?
- Have they spoken about you with constructive criticism or did it have malicious intent (e.g., are they calling you names or are they working out a problem about you with someone else).
- Does the person know you well enough to make a comment about you?
- Does the person become physically aggressive with you?
- Does the person invade your personal space and raise their voice at you, or call you names?
- When asked to stop, does the person continue with the abovementioned behaviors?
- Do these behaviors happen with frequency? If they are not frequent, did the episode/s have severe consequences (e.g., damaging a professional reputation, social reputation)?
It is important to note that a bully does not have to be someone who repetitively verbally or physically attacks someone else. One instance or experience with a bully can have long-lasting emotional effects and implications. I frequently hear from my patients and their parents, “what do we do? Do we have any power in this situation to change these circumstances?” The answer is, yes you do.
- Can you identify the person or persons?
- Are you able to speak with them or their parents to discuss your concerns with their behaviors and see if there is an amicable solution?
- If #2 did not work, is there a teacher, supervisor, parent, or boss to whom you can express your concerns and develop a productive solution?
- If #3 does not work, is there an academic advocate that can work with your child and school to develop a proactive solution without ramifications for the child. Is there a Human Resource advocate that can help work with you to identify a proactive solution that has minimal ramifications for you?
Unfortunately, in dealing with a bully, there can be a “whistle blower syndrome.” You or your child may hear, “well, they must have done something to be treated like this, it’s not a big deal, it’s just normal kid/teenage behavior, just get over it.” Be strong and steadfast. Your mental health and physical safety trump someone else’s need to bully you. Make sure to take care of your kids, teenagers and adults who experience bullying. You have support!
Although I practice in the mental health field, I have countless experiences of my patients recounting stories to me of failed or disappointed experiences with their doctors, both in the mental health and physical health realms.
How can I be my own health advocate is a common question posed by many of my patients. Here are some tips and questions to think about:
- Do you know your diagnoses? Have you asked what they mean?
- Do you think that if you ask too many questions you are a burden to your healthcare provider? P.S. It’s not a burden, although there is always balance. Asking 20 questions a week may be overboard, but most of the time we fall on the other end of the spectrum and don’t ask enough
- Do you know all the options for treatment? Do you know what your treatment will entail? yes, I am a firm believer in evidence-based treatments and I do believe they should be the first-line defense. However, I am not opposed to alternative treatments (as long as they pose no harm) and encourage patients to complement their treatments frequently. In this regard, I like to suggest centering, mindfulness activities, like yoga, to help my patients reaffirm their strategies to exist in the here-and-now.
- Have you gotten a second opinion on your diagnoses and suggested form of treatment?
- If you are getting medication, have you gotten a proper evaluation in order to receive that medication? (All too frequently I hear stories of “i told my PCP that I was sad for a few days and they prescribed me Zoloft.”)
- Have you educated yourself? Great resources are http://www.pubmed.com and http://www.clinicaltrials.gov
- Do you have your medical records organized and copied for your current provider? (it’s very very very helpful when a patient brings in copies of lab data and/or previous psychological or neuropsychological reports; it helps to give clinicians a more accurate picture of what is currently going on).
- Be honest (not just with a clinician, but with yourself).
- Your clinician is not there to judge you, they are there to help. Be open with them.
- Ask questions. If you do not understand something your clinician wants to know. Treatment does not work if you do not know why it is/not working.
- Realize that your clinician is a human too and will definitely make mistakes. It’s a collaborative and honest process on both ends, be willing to work hard and great things can be accomplished.
Communication is key in any therapeutic relationship. Many patients believe effective communication means they must verbally convey to the therapist the symptoms they are experiencing and the goals they have for treatment. Yes, those are very essential pieces to successful treatment, however, there needs to be more.
Below I will list out several bullet points that make for an effective therapeutic relationship between therapist and patient and therapist and a patient’s family.
- As a patient, ask the style of your therapist and their theoretical orientation (e.g., cognitive-behavioral, integrative, psychodynamic, etc.).
- As a patient, ask how the therapist thinks you are doing in treatment. A therapist should be honest if they believe the patient is no longer benefitting from treatment, or if a different treatment approach should be recommended.
- If a patient feels that treatment is stagnant, bring this up with the therapist.
- Get your family, friends, spouse and/or partner involved in treatment. Treatment is much more effective when your support system is in place and knows how to support you using your therapeutic skills outside the treatment setting.
- Do your research as a patient. A good resource for new, top of the line, evidence-based treatments is pubmed.com. You can also look at PSYCHinfo. Bring new studies into your clinician if you are interested and discuss potential implications for your treatment. We WANT you to be involved!
- Be your own advocate! So many times I see patients hesitant to question a recommendation by myself or other professional doctors. We are here to answer your questions and make sure you understand your treatment and progress. This is a collaborative process. Asking questions and being involved IS NOT being burdensome. We want you to ask away!
- Be honest. This is a hard one because sometimes it may be difficult to even be honest with ourselves. If a major stressor in a family is not discussed (e.g., a parent is very sick and a child is being treated), this will directly impact the treatment goals and progress in therapy. Be as honest as you can about your ENTIRE situation.
- If you feel like you cannot pinpoint it, but you do not get along with your therapist it is important to tell them. Most of the time, potential personality clashes are miscommunications. However, sometimes they are not and therapists can refer you to other clinicians who would be a better fit. As psychologists, we believe this to be a very important piece to treatment and do not take offense if there is not a good “personality fit.”
- Make sure your therapist is listening to your concerns. How does one know this? You can ask them to summarize your concerns and include them in the treatment plan. Over the years many of my patients have brought concerns to the table that would be deemed non-clinical, but to them, they were ranked higher in terms of importance than the clinical concerns. It is important to convey this to your clinician.
- Overall, be willing to work with your clinician and give the process the time it needs and deserves. Sometimes treatment takes 1-3 months, other times, it may take 2-3 years.
Wishing you well on your therapeutic journeys!