Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

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Tag: Confidentiality

Thursday, October 8th, 2009

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.

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Wednesday, October 7th, 2009

Confidentiality in Adolescent Psychotherapy

Confidentiality is a cornerstone of the therapeutic relationship. The ethics of my profession require that all communication between my patients and me remains confidential. In other words, I cannot disclose the information a patient reveals in session, or my own impressions about a patient, to anyone without the patient’s explicit written consent. Of course, there are exceptions to the rule. I am a mandated reporter of child abuse, and if a patient is imminently suicidal or homicidal, I have a duty to notify the appropriate parties in order to save the patient’s life and protect the public. But these scenarios are relatively uncommon.

Undoubtedly, confidentiality is an important, if not essential, therapeutic tool. Patients are far more likely to enter therapy, and to be completely honest and forthcoming in therapy, when they know that “what happens in therapy stays in therapy.” I am honored and humbled, though not necessarily surprised, when a patient tells me that I am the first person she has ever told about a particular trauma, event, thought, or feeling. A therapist’s office is a safe place in which a patient can express anything and everything without fear of judgment, alienation, or other negative repercussions. Through this vulnerability and brutal honesty comes an opportunity for growth and meaningful change.

However, confidentiality is not without its problems. For example, psychologists often struggle with decisions as to whether to disclose information about adolescent patients to their parents. On the one hand, parents have a legal right to obtain health care information regarding their child, and they are technically the “holders” of any privileged communication between their child and her therapist. On the other hand, adolescents can undoubtedly benefit from discussing certain personal issues with a nonjudgmental third party outside their family, and they are less likely to raise such issues with their therapist if they know that the information will get back to mom and dad.

I know of some psychologists who share very little with the parents of their adolescent patients. After all, they argue, the primary developmental tasks of adolescence include separation from family and establishment of an independent identity. These psychologists believe that they are respecting the adolescent’s burgeoning sense of identity by excluding parents from treatment. They also believe that they are nurturing the therapeutic relationship by refusing to disclose all but the most essential information to an adolescent’s parents. Many of these therapists believe that the parents are guilty of causing or contributing to their child’s problems, and thus are best kept out of the treatment picture. As a result, many parents of adolescent patients are relegated to the role of chauffeur. They drive their child to her appointments and pay for her treatment without ever knowing what is going on in those sessions. Imagine how disempowering it must feel for a parent to be relegated to such a role.

To be sure, psychologists who practice this way make many valid points. However, I have a different perspective on my role as a therapist and on the role confidentiality plays in my work with adolescent patients. Consequently, I approach the issue of confidentiality with adolescent patients differently. Empirical research has demonstrated, and my own clinical experience has confirmed, that adolescent treatment generally works best when parents are fully informed and actively involved, and I communicate this point to my adolescent patients and their parents at the start of our work together. I am relatively unconcerned when I meet an adolescent patient who lacks insight or motivation or who resists treatment. I am very concerned when the parents of an adolescent patient are unwilling, unmotivated, or unable to play an active role in their child’s treatment.

When I work with adolescents with relatively normal social or developmental concerns (e.g., grief, problems with friends, sexuality, stress management, body dissatisfaction), parents play an important, though relatively minor, role in treatment. In these cases, the work is primarily between the adolescent and me. Even so, I involve parents in the initial evaluation, treatment planning, and discharge planning; I provide them with empirical literature on their child’s problem and the treatment approach I am using; I provide them with guidance as to how they can support their child at home; and I invite them to call me or schedule an appointment with me at any time if they have questions or concerns about their child.

In my work with adolescents with mental illnesses, parents play a central role as indispensable members of the treatment team. I take an authoritative stance regarding my knowledge of, say, major depression or anorexia nervosa, while also maintaining humility by respecting parents’ judgment and intuition regarding their child. I may be the expert on mental health, but they are the experts on their child.

Adolescents who are struggling with serious mental illnesses, such as bipolar disorder, major depression, anorexia nervosa, and bulimia nervosa, require treatment which is more intensive and more comprehensive. These patients need their parents to play an active role in managing their symptoms and creating an environment which is conducive to recovery. In order for parents to do this, they need to be informed about their child’s symptoms and progress. While I certainly do not share everything a teenage patient says in therapy with her parents, I do provide her parents with the information they need in order to help her get better.

The parents of adolescents with mental illnesses are often overly stressed, worried, isolated, and confused. These parents need considerable support, encouragement, and guidance as they learn to cope with their child’s illness and support her through her recovery. This one of the reasons why I am so fond of family-based treatment: I get to empower the family to support the patient, drawing upon the parents’ intimate knowledge of and investment in their child. Instead of pulling the patient away from her family, I strengthen her natural support system, which makes intuitive sense to me. After all, therapy is time-limited. Family is forever.

Family members are also vital in preventing relapse, as they are generally the first people to notice a change in their child’s mood or behavior. Equipped with the right knowledge and skills, parents can intervene immediately and help to pull their child back from the brink of relapse, often preventing the need for future treatment.

Does involving family members in treatment damage my relationship with my adolescent patients? In the short term, it often does. Keep in mind, though, that some families bring their adolescents to me after an unsuccessful course of traditional individual therapy in which the patient had a very special, exclusive relationship with her therapist (who may have implicated her parents in the etiology of her problems) but made no meaningful progress whatsoever. My therapeutic relationship with adolescent patients is certainly important, but it is far less important than strengthening her relationship with her family and taking the necessary steps to help her recover. As adolescent patients progress through recovery and gain more insight, they gain trust in me and in their parents. They gain faith in the recovery process, and most of them are grateful for the fact that their parents and I worked collaboratively to help them. As much as they may resist it, adolescents need boundaries and limits, and they need adults to work together on their behalf.

By involving parents so heavily in an adolescent’s treatment, am I disrupting the processes of separation and individuation? In the short term, yes. I would argue, however, that cutting, starving oneself, engaging in unprotected sex, and throwing up after meals are not acceptable ways of exerting control or establishing identity. The supposition that a certain unhealthy behavior serves a valuable emotional or developmental purpose does not justify allowing that behavior to go unchecked. It is the mental illness which hinders adolescent development, not the treatment. Adolescents struggling with crippling depression or anxiety, erratic mood swings, self-injury, or life-threatening eating disorders are unlikely to blossom into well-adjusted, independent young adults without significant support. Empowering an adolescent’s parents to help her overcome a mental illness is ultimately very respectful of adolescent development – it allows the patient to recover within the safety and security of her natural environment so that she may one day live independently, unencumbered by mental illness.

For these reasons, my relationship with the parents is just as important as my relationship with the adolescent patient. Parents need to trust my judgment and treatment methods. They are, after all, entrusting me with their child’s health and bright future. I believe that I earn parents’ trust by maintaining open lines of communication between us, by providing them with empirically-sound literature on their child’s condition and the treatment approach we are taking, by respecting their parental instincts and taking seriously their experiences with their child, by supporting them emotionally, by absolving them of guilt and self-blame for their child’s disorder, and by empowering them to take constructive action.

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