Metamorphosis: Long-Term Therapy with Young Adults

One of the most rewarding aspects of my job is the opportunity to engage with patients in long-term therapy.  In my practice today, I have a number of patients who began treatment with me years ago, in adolescence, and are now in their 20’s.  These patients first presented in my office with their parents during middle school or high school, suffering from severe eating disorders or depression or debilitating anxiety or, in some cases, all of the above.  Some entered treatment kicking and screaming; others reluctant but resigned; still others wanting help and suffering desperately but requiring immense parental support to stay afloat.

 In many cases, these adolescent patients received intensive Family-Based Treatment for six months or a year or more.  In other cases, the teenage patients received individual Cognitive-Behavioral Therapy with active parental involvement.   All of them made substantial progress in treatment.  The majority recovered fully from their initial presenting diagnosis.  Those who have not recovered fully are doing significantly better, living independent, fulfilling lives, but still experiencing symptoms and receiving ongoing care to keep their illness at bay.  Now, years later, some of them continue with weekly therapy sessions.  Others come in once or twice a month, or perhaps biannually like dental cleanings (we call this “mental hygiene”).  Still others elect come in on an “as needed” basis, scheduling a few sessions here and there to help them cope with life events, navigate relationships, manage stress, or deal skillfully with bouts of depression or anxiety. 

What unites these incredible young men and women is the fact that they have taken full responsibility for their well-being.  They have chosen to engage in long-term individual therapy as an act of self-care.  Through their adolescent suffering, they have become acutely aware of their susceptibility to mental illness.  They are choosing to receive therapy not only to prevent relapse of illness but also to pursue optimal health.   Many of these young adults have chosen to abstain from drugs and alcohol, even as their peers regularly smoke pot and drink to excess.  Many of them have adopted consistent home practices of meditation or yoga.  They make conscious, health-promoting choices when it comes to sleep, nutrition, stress management, and physical activity.  When faced with an important decision about which graduate program to pursue, which job offer to take, which city to live in, or even which person to date, they carefully consider the impact of these choices on their quality of life.

Engaging in long-term therapy with patients like these involves a number of gradual but significant transitions for all members of the therapeutic relationship: the patient, the parents, and me.   For the parents and for me, there is the progression from the crisis management of an acutely ill adolescent to the joy of stepping back into a supportive role for young adult in his own quest for greater levels of well-being.  The parents and I often begin our relationship communicating multiple times per week to put out fires and to ensure that we are in lock-step as we form a circle of safety around a suicidal or eating disordered patient.  As the patient gradually assumes responsibility for her own well-being (which often takes several years for those with adolescent-onset mental illness), communication between parents and me subsides into an occasional email or phone call.   The patient is now a much healthier, more mature young adult, and is trusted to schedule, attend, participate meaningfully in her own therapy sessions.  In many cases, she pays for her own treatment as well.

The therapy itself goes through a significant evolution as I shift from being directive and prescriptive, setting firm limits around dangerous or debilitating symptoms, to engaging with the patient in deep psychological work and collaborative goal setting.  For the patient, there is the very welcome shift from being told what she must do, in therapy and at home, to deciding what issues are important to her and taking the initiative to seek support, both therapeutic and familial, in achieving personally relevant goals.    For the patient, this shift brings with it a transformation from a defensive posture (as evidenced by panicking, shutting down, or lashing out in therapy and at home) to a stance of openness and receptivity (as evidenced by increased self-disclosure and self-awareness along with the display of more vulnerable emotions). 

I cannot begin to describe how rewarding it feels to support a frightened, malnourished, deeply depressed teenager as she blossoms into a healthy, confident, independent young woman who is attending college or graduate school in another state, working at an exciting full-time job, getting married, or giving birth to her first child.  It is fulfilling beyond words to join with young adult patients in the journey of long-term wellness as they clarify their personal values, decide who they want to be in this world, and take concrete steps towards achieving their dreams.

Those of you who have engaged in long-term therapy, either as a therapist, as a patient, know well how deeply personal and meaningful these relationships can be.  There is a level of emotional intimacy that surpasses even that between spouses, between parent and child, or between the best of friends.   In many ways, engaging in long-term therapy with self-motivated young adults is the polar opposite of Family-Based Treatment (FBT) for Adolescent Anorexia Nervosa.   For most patients in my practice, the former would not have been possible without the latter.   

For Teens, Smartphone Dependence Predicts Later Depression

We have known for years that excessive smartphone use is correlated with depression. However, until recently, the direction of causality was not known. Does excessive smartphone use cause people to become depressed? Or do people who are already depressed use their smartphones more often, leading to unhealthy dependence? A recent study published in the Journal of Adolescent Health lends support to the former hypothesis. This study, which followed adolescents between the ages of 17-20, found that dependence on smartphones at the start of the study predicted depression and loneliness three months later.

Although the mechanism of action here is not yet known, I have several thoughts about why and how excessive smartphone use can lead to depression. First, there’s the neurobiological effect of the smartphone use itself, which activates the Sympathetic Nervous System (“fight or flight” response), increases threat perception, and disrupts sleep. The Sympathetic Nervous System (SNS) is designed to protect us from danger by elevating heart rate, increasing levels of cortisol, and giving us the burst of energy we need to fight off a predator or flee from danger. The SNS is meant to be activated periodically, and for limited durations of time, when danger is present until danger passes. It is not meant to be activated every few seconds, all day long, each time we receive a notification on our iPhone. Over time, chronic SNS activation leads to depletion and depression. So does sleep deprivation.

Second, there’s social comparison. Adolescents are especially vulnerable to peer influence and frequently compare themselves to others to gain a sense of their social standing. Teens who spend excessive amounts of time scrolling through social media are likely to judge themselves unfavorably compared to others. It is all too easy for these teens to conclude that other people are prettier, thinner, happier, more successful, and having more fun than they are. Of course, most people only post pictures of themselves looking great, having fun, and doing interesting things, even if the majority of their lives are spent looking average and completing mundane tasks like homework and chores. Nonetheless, upward social comparisons such as these tend to lower self-regard, and poor self-esteem fuels depression.

Finally, excessive smartphone use has to replace other activities. There are only 24 hours in a day. If a teen is spending 15 hours per day on his smartphone, what is he NOT doing? Well, for starters, he is probably not getting a good night’s sleep. He is probably not eating balanced meals with his family, or if he is, he’s eating mindlessly while scrolling through social media rather than engaging in meaningful conversation with his parents and siblings. He is probably not present or engaged in class, and he is constantly distracted while doing homework (if he even does homework), which means he is not learning much nor reaching his academic potential. He is not getting much physical activity or time outdoors. He may not be participating in social activities (of the in-person variety), or clubs, or hobbies, or lessons, or volunteer work, or religious services. In other words, the habits and activities that have been proven to help us stay healthy and balanced and socially connected, that give us a sense of meaning and purpose in life, are notably absent in those who are dependent on smartphones.

In my clinical practice, I strongly encourage teens and young adults to limit their screen time. To promote restful sleep, which is essential for both physical and mental wellbeing, I recommend turning off all electronic devices one hour before bedtime and leaving them off overnight. It is remarkable how much better teenagers sleep, and how much better they feel during the day, when they turn off their phones and computers by 10:00 pm, relax before bedtime, and sleep a full 8 hours.

For individuals who experience body image distress or social anxiety, limiting use of social media can help reduce symptoms. This could involve unfollowing certain people who are especially triggering, or simply limiting the amount of time spent on social media to 30 minutes per day, for example. I will never forget the 15-year-old girl who suffered from Generalized Anxiety Disorder who, upon getting rid of SnapChat for a week, experienced complete relief from her symptoms! Unfortunately, she later returned to SnapChat and began experiencing more anxiety. Eventually, she figured out a way to set limits on her SnapChat use, which allowed her to remain connected with her friends while causing only a slight increase in anxiety. Personally, I would have gotten rid of SnapChat completely and permanently, but try telling that to a very social, strong-willed 15-year-old.

Like many technological advances that preceded it (the automobile, the television, the internet), the smartphone is a wonderful invention that has improved the quality and efficiency of our lives. But there is a fallout from many technological advances, particularly when they are used carelessly or in excess (e.g., global climate change, couch potatoes, cyber-bullying). The smartphone is no exception.

Fighting Stigma: The Gift of a New Generation

Somehow, sometime in the past several years, I crossed some invisible line from “young adult” to simply “adult.”  Polite strangers call me “ma’am” at least as often as they call me “miss.”  Shopping at Forever 21 now seems scandalously inappropriate.  And I can’t remember the last time I was still awake to watch Saturday Night Live.  Now that I seem to be old enough to complain about the younger generation (They think women’s empowerment is posting bikini-clad selfies!  They use social media excessively! Their pivotal relationship conversations take place over text message!), it seems only fair that I also recognize the strengths of this cohort.  And they do have tremendous strengths.

Teenagers and young adults these days, for the most part, have grown up in an era where it is socially acceptable, even encouraged, to speak openly about mental health issues.  Just about every high school and college student who walks into my office has at least a couple of friends with mental health diagnoses.   Most of my patients have one or more members of their extended family, if not their immediate family, who has dealt with a mental illness.   And they know this because they talk openly about it.

And that excessive use of social media I complained about a minute ago?  Well, social media has allowed famous people to speak candidly to a wide audience about their experiences with mental illness, seeking treatment, and ultimately recovering.   Actress Kristen Bell has struggled with depression.   Writer/producer/actress Lena Dunham has received treatment for OCD.  Singer Demi Lovato has spoken openly about her struggles with bipolar disorder and her recovery from an eating disorderJohn Green, author of The Fault in Our Stars, has chronic anxiety which he is able to control with therapy and medication.  Olympic swimmer Michael Phelps has a diagnosis of ADHD.  These individuals have been extremely successful in their professions and have had the courage to speak publicly about their psychiatric problems.

Even more courageous than these celebrities, though, are the regular people who attend school, play sports, hold down jobs, pay bills, raise families, volunteer in their communities, and maintain friendships while also dealing with mental illness.  These are the people who have a lot to lose from the stigma surrounding mental health issues.  These are also the people who have the most to gain from breaking down the stigma.

The younger generation is fighting this stigma.  Australia’s National Youth Mental Health foundation has created an organization called Headspace dedicated to supporting adolescents and young adults with mental illnesses as well as combating stigma surrounding these issues.  In the UK, Prince William, Princess Kate, and Prince Harry have created Heads Together, a charity dedicated to fighting stigma surrounding mental illness and improving the mental well-being of all citizens.  Here in the US, the National Alliance on Mental Illness (NAMI) is running a Stigma-Free campaign.

The message of these organizations is simple and straightforward: mental illness is common and treatable.  Mental health problems are as much a part of the human condition as any other health problem.  Untreated mental illness can have dire effects on the individual, on the family, on the community, and on society as a whole.  People who have psychiatric diagnoses can overcome them and live fulfilling, successful, meaningful lives.  Learn about it.  Talk about it.  Seek treatment when needed, and support others in doing so as well.  Silence and shame help no one.

I can’t recall ever hearing these messages as a teenager or young adult.  If these messages existed at all back in my day, they were eclipsed by the OJ Simpson trial, overshadowed by the Clinton/Lewinsky scandal, drowned out by the Spice Girls and ignored amidst episodes of Friends.  It is an honor and a privilege for me to treat the teens of this generation, who live their lives with more knowledge, understanding, and acceptance than the generation before them.

If you’d like to read an interesting perspective from a highly experienced clinician from a previous generation who has over 40 years of experience treating anxiety and eating disorders, see Dr. Paula Levine’s blog.

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.

Everything I Need to Know I Learned From Adolescents

A 31-year-old woman named Monica recently died from anorexia nervosa (AN) following a 15-year battle with the disease. Her death is an eerie reminder of what we already know: eating disorders are dangerous, deadly, and difficult to treat. Traditional treatment for AN typically takes 5-7 years. Less than half of patients with AN will ever fully recover, and of those who do recover, one-third will relapse. Nearly 20% of patients with AN will die as a result of their illness.

Just a decade ago, only 30% of patients fully recovered, and now nearly 50% will fully recover. The reasons for the improved prognosis include greater awareness about eating disorders, which leads to earlier diagnosis and treatment, and the advent of more effective, evidence-based treatment for adolescent AN, such as Maudsley Family-Based Treatment. But early diagnosis, early intervention, and the Maudsley method primarily benefit adolescents. Consequently, I would presume that the 20% increase in recovery rates over the past decade is primarily due to the recovery of more adolescents, not the recovery of more chronically-ill adults.

Although AN typically begins in early adolescence, those who die from the disease are more often adults who have battled it for many years. The most effective course of action is early diagnosis and aggressive, evidence-based treatment as soon as symptoms appear. Unfortunately, there are countless adults with AN who have struggled for years or even decades. As of this time, there are no evidence-based treatments for adults with AN, nor are there any medications which have been proven to benefit adults with AN. CBT has been shown to be moderately beneficial in preventing relapse in weight-restored AN patients but shows no benefit in underweight anorexics.

A lot of the AN treatment offered today is outdated and ineffective. Fortunately, however, there are more and more clinicians and treatment centers who are adopting modern, evidence-based approaches to treating adolescent AN that have much higher success rates. For example, the Kartini Clinic, the UCSD 5-Day Intensive Family Program, and the Children’s Hospital at the University of Chicago have adopted a highly-practical family-based, evidence-based approach to treating adolescent AN based on the Maudsley Method.

We can learn a lot from the success of these adolescent programs. I believe that we can use the basic principles of Maudsley FBT and the philosophy of these adolescent treatment programs to develop effective treatments for adults. Medicine, psychology, and psychiatry do this all the time in the reverse; that is, they extend effective adult treatments to adolescents. If a particular medication or psychotherapy approach demonstrates effectiveness in adults, clinicians automatically begin using it in adolescents, often without any research data to support its use in this population. Clinical trials are then conducted on adolescents, and research data follows.

Consider the basic principles of Maudsley FBT:
1. Conceptualization of AN as a biologically-based brain disorder of unknown origin
2. Externalizing the illness
3. Viewing family members as vital resources in a patient’s recovery
4. Recognition that most of the symptoms of AN are direct result of malnutrition and thus will abate after weight restoration
5. Focus on nutritional rehabilitation and weight restoration as non-negotiable first priorities in treatment
6. Acknowledgment that patients with AN are unable, in the acute phase of illness, to make healthy decisions regarding food and weight
7. Coaching parents to provide emotional and nutritional support to their child
8. Addressing psychological symptoms and other comorbid disorders after weight restoration

Which of these principles are irrelevant in the treatment of adults?

I see no logical reason why we cannot use Maudsley FBT in the treatment of adults with AN. Based on the patient’s circumstance and living situation, spouses, roommates, friends, or significant others may be enlisted for meal support in lieu of parents. The specific details may need to be tweaked in order to be relevant to an adult patient’s situation, but the general principles would remain the same. After all, the physical and psychological symptoms of AN are the same regardless of whether the patient is an adolescent or an adult. AN stunts growth and development and prevent sufferers from becoming independent, fully-functional beings. Thus, adults with AN are regressed physically, sexually, and socially to the point that they often resemble adolescents anyway.

The differences that do exist between adolescent and adult forms of AN are not inherent to the disease itself or even to the age of the patient. Rather, they are imposed by society. We, as a society, have arbitrarily determined that teenagers are fully responsible for their own healthcare decisions once they reach their 18th birthday. This is the case regardless of whether the patient has an ego-syntonic, anosognosic condition such as AN which impairs their judgment and insight. By virtue of their illness, adults with AN are unable to make healthy decisions for themselves. And yet, the law prohibits parental involvement, even parental notification of treatment, unless the patient signs a release. The law clearly sides with AN, not with the patient.

Family support and family involvement are powerful predictors of good outcome. Unfortunately, most therapists consider parental involvement in an adult patient’s treatment unnecessary or even detrimental. These therapists believe that the etiology of AN is rooted in controlling parents, separation anxiety, and issues related to independence and autonomy. Thus, they keep patients separated from the very people who love them most and who may be best equipped to help them achieve full recovery. This is counterproductive because a patient’s physical and psychological wellbeing must always take precedence over the developmental issues of emerging adults which, incidentally, have never been proven to be causally related to AN. Adult patients’ lives are threatened as a result of ignorant adherence to an unproven theory.

I firmly believe that Maudsley Family-Based Treatment can be effective in young adults. In fact, I have used this approach with young adults in my practice with great success. I have seen patients who have been sick for a decade, hospitalized multiple times, and endured several courses of ineffective residential treatment finally achieve recovery as outpatients through FBT. I look forward to the day when FBT is widely available to adults, as well as adolescents, with AN.

Helping College Students With Mental Illnesses

Yesterday I blogged about the issue of confidentiality in psychotherapy with adolescents. The issue of confidentiality becomes more problematic once patients turn 18 because laws and ethical guidelines seem to work in opposition to family involvement. Having completed most of my training in university counseling centers, I can safely say that whatever law designated 18 as the “age of majority” is clearly in need of revision. Teenagers don’t suddenly become more responsible, more mature, more mentally stable, more independent, or more capable on their 18th birthday. Our knowledge of neuroscience supports this: the brain’s frontal lobes, which govern higher-level cognitive functioning (e.g., planning, decision-making, and impulse control), are not fully developed until the early- to mid- twenties. Moreover, the financial and social realities of our generation have extended adolescence well beyond the tender age of 18.

Most normally developing college students without mental illnesses rely on their parents for financial, emotional, and practical support, not to mention a roof over their heads during holidays and summer vacations. Now add to that the immense strain of being at a new school in a new environment in a faraway city, without your friends or family or the professionals who have treated you for years, while dealing with a mental illness. In previous generations, most of these students with mental illnesses would not have made it to college, but with the advent of more effective medications and evidence-based psychological treatments, most of them can live independently and lead relatively normal lives as long as proactive steps are taken to manage their disorders. Their chances of succeeding are far greater when their families remain fully informed and actively involved in their treatment, at whatever level is clinically indicated given the nature of their illness and mental state, NOT THEIR CHRONOLOGICAL AGE.

University counseling centers have been slow to adapt to the changing realities of their student bodies. Just a generation ago, college counseling centers dealt primarily with breakups, homesickness, test anxiety, and roommate quarrels. Under these circumstances, there is usually no need to involve parents in treatment, and students are generally capable of reaching out to their parents for help if needed. Nowadays, the typical university counseling center client has already been diagnosed with and treated for at least one, if not two or three, mental illnesses prior to entering college, such as bipolar disorder, OCD, ADHD, major depression, or anorexia nervosa. Many more clients have no history of treatment prior to college, but are experiencing the first signs and symptoms mental illness. After all, the average age of onset for many mental disorders is late adolescence to early adulthood, which happens to coincide with the college years.

Here’s the problem: many university counseling centers operate AS IF their clients were dealing with typical adjustment problems or social concerns. They view their clients’ problems as manifestations of typical developmental issues or of difficulty adjustment to the college environment. They treat 18-year-old students with mental illnesses AS IF they are healthy, independent, insightful adults who can and should make appropriate decisions about their mental health care. OFTEN, THEY CANNOT.

Unless a college student signs a waiver, her parents are not even permitted to know whether she is in treatment at all. If parents are not informed about their child’s symptoms and progress, they cannot intervene when necessary. Unfortunately, many mental illnesses, in their acute stages, impair judgment and insight or render the patient incapable of accurately reporting her symptoms or seeking the necessary help. The administration rarely intervenes unless a student is in imminent danger of killing herself or others. The end result? Many college students struggle for months or years before entering appropriate treatment. This delay in getting adequate care wastes time, exacerbates the student’s misery and the parents’ worry, and prolongs the recovery process.

Universities have come so far over the past couple of decades in terms of welcoming and embracing students of color, students of non-traditional age, students from foreign countries, students from disadvantaged backgrounds, students of all religions and races and sexual orientations. Universities have also made tremendous strides in terms of understanding and accommodating students with learning disabilities, ADHD, sensory impairments, and physical disabilities. Universities offer testing accommodations, build wheelchair ramps, hire sign language interpreters, offer classes on line and on weekends, recruit students from poor minority neighborhoods, and organize GLBT alliances. These changes have benefitted the universities, their students, and the nation as a whole.

I would like to see universities institute similar changes to help students with mental illnesses. For starters, they could really start to examine what students with mental illnesses need in order to thrive in college and make the necessary changes to ensure that these students’ needs are met. They could expand their mental health services to include larger counseling center buildings, offer more intensive and comprehensive mental health services, hire more psychologists and psychiatrists, and attract better psychologists and psychiatrists by offering competitive salaries. When an incoming freshman has been previously diagnosed with a mental illness, the university counseling center staff could meet with the student and her parents during orientation to obtain her history, develop a treatment plan collaboratively, open the lines of communication between home and school, and plan ahead for any potential problems or relapses.