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 trained scientist-practitioner, and 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, and 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: mental illness

Saturday, February 13th, 2010

How to Choose a Therapist

A good therapist is hard to find. I’m new to the field, relatively speaking, and I’ve already encountered a number of horrible therapists as well as many outstanding ones.

Finding a good therapist is trickier than finding a good dentist or gynecologist. Most people choose their healthcare providers based on a three simple factors: proximity to their home or work, whether the provider takes their insurance, and personal recommendations. For most healthcare issues, this works out well. After all, a biannual dental cleaning is a biannual dental cleaning; a pap smear is a pap smear – there’s not a whole lot of variation in how these procedures are done. You can be pretty confident that you’re getting decent care regardless of which doctor you choose. If you don’t like your doctor, no big deal – you only see her once or twice a year, and besides, she takes your insurance and she’s two blocks away from your office! You may opt to switch doctors due to a negative experience with one or a change in insurance coverage, but this is not a big deal either. You just go back to square one and choose someone based on those initial three criteria.

Choosing a therapist is not so simple. Therapists are not interchangeable like dermatologists or orthodontists. The treatment you get with one therapist differs tremendously – in terms of the nature of treatment, the type of treatment, and the quality of treatment – from the treatment you would get with other therapists. The problem is that most people outside the field are not aware of this, and it is difficult to find out what you are getting before you get it. The licensing process does very little to weed out incompetent psychologists. The two written exams we must pass – one based on a general knowledge of psychology and one based on state laws and rules for psychologists – have no predictive validity in determining whether someone is a good therapist. Basically, therapists can do whatever they want in their sessions, so long as it doesn’t violate ethical codes. Therapists are not prohibited from practicing outdated, ineffective treatments. Although research has shown certain psychological treatments to be vastly superior to others for certain disorders, the majority of therapists do not use these empirically-supported treatments.

Choosing a therapist based on proximity alone is not a good idea. The therapist closest to you may not be a good fit for you. Choosing a therapist based on insurance alone is also not a good idea because many therapists don’t take insurance. Further, if you do use your insurance to pay for treatment, the insurance company will likely request a great deal of personal information about your mental health conditions, may discriminate against you based on diagnosis (or lack thereof), and will probably limit the number of sessions you can receive. Getting personal recommendations for therapists is tricky because it involves disclosing at least some personal information to a friend or colleague, and many people are not comfortable doing that. It is not always wise to choose a therapist based on how much experience she has in the field, because many therapists who have been practicing for decades remain entrenched in antiquated theories of mental disorders and practice less effective treatments Also, if you are a young person, it may feel more comfortable to talk to someone closer to your age who can relate to you more easily and who has a better understanding of your generational issues.

So how do you choose a therapist? Well, that depends on why you’re seeking therapy. If you need some support in dealing with normal developmental or social stressors (e.g., death of a friend or family member, relationship issues, stress management, divorce or breakup, difficult transitions), it is helpful to use the following selection criteria:

• A personal recommendation from a trusted friend may be helpful in this case.

• Find someone who has experience dealing with the types of issues you are facing. For example, if your sibling just died, find a therapist who is experienced in working with grief.

• Consider whether you have a preference in terms of your therapist’s gender, ethnicity, age, or sexuality. Many people prefer to work with a therapist of their same gender and/or someone who is close to their age. Many LGBT clients prefer therapists who are openly gay or lesbian, or who have considerable experience working with these populations. Some ethnic minority individuals prefer working with someone who shares their ethnic background. On the other hand, some clients don’t have demographic preferences, and that’s OK too.

• Find a therapist with whom you feel comfortable. You may need to have a session or two with the therapist before really being able to tell whether it is a “good fit.” Developing a strong, trusting therapeutic alliance will facilitate the healing process.

• Find a therapist who is a clinical psychologist (Ph.D. or Psy.D.), Licensed Mental Health Counselor (LMHC), Licensed Clinical Social Worker (LCSW), or Marriage and Family Therapist (MFT).

When you are seeking treatment for a mental illness, such as major depressive disorder, OCD, anorexia nervosa, PTSD, or borderline personality disorder, I would recommend using a different (and more stringent) set of selection criteria because the stakes are higher. Having a good therapist is a powerful predictor of your chances for recovery, so it is important to take the therapist selection process seriously. Most therapists offer free phone consultations in which you can briefly describe your issues and ask about her qualifications and approach to treatment. I recommend using the following selection criteria in choosing a therapist to treat a mental illness:

• Do as much research as you can on your diagnosis and effective method(s) of treating your particular condition.

• Look for a therapist who specializes in providing evidence-based treatment for your disorder. For example, if you suffer from OCD, you will want to find a therapist who specializes in OCD and practices behavior therapy. You can find out this information by looking on the therapist’s website (if she has one) or simply by calling to ask her about her specialties and her treatment approach.

• Ask the therapist about her views on your particular disorder and the treatment thereof. If her explanation of your illness is unscientific (e.g., “Anxiety disorders are the result of unresolved inner conflicts”) or if her treatment approach sounds flaky or non-directive (e.g., “I provide clients with a safe place in which they can explore their issues”), move on to someone else. It’s great to explore your issues in a safe place, and this may be exactly what you need when struggling with the normal developmental or social stressors described above. If you have a mental illness, however, you’re going to need a whole lot more than that in order to recover.

• Look for a therapist with a doctoral degree in psychology (Ph.D. or Psy.D.). Doctoral level psychologists have 5-7 years of graduate training and supervised clinical practice, plus a post-doctoral residency. Most Ph.D. programs in clinical psychology are extremely selective and have very low acceptance rates (for example, 250 applications for 6 slots). In addition, Ph.D. psychologists have extensive training and experience in scientific research. While a Ph.D. in clinical psychology does not guarantee therapeutic effectiveness, it does reflect a high level of ambition and academic accomplishment, a scientific background, and at least five years of intensive, high-quality training. In contrast, a master’s level therapist such as a social worker (LCSW), licensed mental health counselor (LMHC) or marriage and family therapist (MFT) has significantly less clinical training (usually 2 years of graduate school) and very little, if any, training in scientific research. Psychiatrists are medical doctors (MD’s) who focus primarily on prescribing psychotropic medication. Some of them provide psychotherapy in addition to medication, but most do not. Their training is primarily in the practice of medicine, not scientific research or psychotherapy. Most psychiatrists these days have little training in psychotherapy. Of course, there are exceptions to this rule. If you decide to see a psychiatrist for therapy, make sure she is one of the exceptions.

• University-based mental health clinics and academic medical centers are excellent places to seek psychological treatment. Many of them offer low-cost services or provide treatment for free as part of research studies. The therapists are typically doctoral-level graduate students, pre-doctoral psychology interns, and/or post-doctoral residents, all of whom are closely supervised by licensed clinical psychologists. Advanced graduate students, interns, and post-docs tend to make excellent therapists because they are young, idealistic, energetic, fully informed about recent advances in the research and practice of therapy, well-trained, and constantly evaluated on their performance.

• Find a therapist whose patients actually recover. The proof is in the pudding. Ask the therapist how many patients with your diagnosis she has treated in the past three years, and how many of those patients have fully recovered. If she hems and haws, or describes therapy as a lifelong journey, or claims that one never recovers from your particular disorder, move on to someone else.

• If the therapist is empathic, great. If she’s really nice and makes you feel at ease, wonderful. If you feel very connected to her, fantastic. These qualities are important, but if you are struggling with a mental illness, what matters most is whether she can help you recover. Mental illnesses are treatable and manageable; some are even curable. So don’t mess around with your mental health care. If you had cancer, your priority would not be finding an oncologist who was warm and kind and empathic and emotionally connected to you. These qualities are icing on the cake, but what you need most of all is the cake. And the cake is effective treatment that will cure your cancer. Don’t need to settle for anything less in your mental health care.

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Posted in Psychotherapy | 8 Comments »

Thursday, January 28th, 2010

What’s Wrong With Mental Health Care in America?

Just about everything.

I can sum up our country’s mental health care problem in one sentence: Failure to provide local, high-quality, comprehensive, affordable, evidence-based mental healthcare for every American citizen, at the appropriate level of intensity, for as long as necessary for full recovery and relapse prevention.

Few Americans have access to local high-quality, evidence-based mental healthcare. Some people find mental health care cost-prohibitive. Others struggle to make ends meet, dipping into their savings, wiping out their retirement accounts or college funds in order to afford appropriate mental health treatment for themselves or their loved ones.

Societal ignorance is partially to blame for this problem. Although “the stigma” of mental illness has allegedly been reduced in recent decades, I see it all around. Like racism and sexism, the stigma of mental illness is perhaps less overt now than it was in previous generations, but it is alive and well today in all of its subtler forms. Many insurance plans do not provide coverage for mental health care. This conveys the message that mental health treatment somehow optional, unimportant, or extracurricular. The brain is arguably the most important part of the body, so why should treatment of brain diseases be viewed as less essential than ophthalmology, endocrinology, or dermatology?

Even more infuriating to me is the reality that mental illness itself is not nearly as stigmatizing as GETTING TREATMENT FOR MENTAL ILLNESS. Consider the following:

• As a graduate student, I read about a medical insurance policy that parents of college students can take out for their children. This policy allows parents to receive a full tuition refund if their child withdraws from school mid-semester for medical reasons. However, the policy specified that, if the student withdraws due to “a nervous or mental disorder,” the parents would receive only a 60% refund. The implication here, as I see it, is that students with mono or renal failure or cancer have “legitimate” illnesses that are neither their fault nor their choice, whereas students with bipolar disorder or anorexia nervosa or major depression are at least partially to blame for their problems, which are seen as less “real,” and they could stick it out for the rest of the semester if they really wanted to. This policy creates a situation in which students struggling with severe mental illnesses feel pressured to remain at school, away from their primary support system, with inadequate treatment, for the duration of the semester, rather than returning home to their families to recover and pursue more intensive treatment.

• Many universities require students who have been out on medical leave for mental health reasons to have a readmission assessment with a mental health professional before being permitted to matriculate once again. Students who were out on medical leave for physical illnesses are not required to submit to a physical exam upon their return to school.

• In the state of Florida (and perhaps in other states), aspiring attorneys must answer a question on their bar application asking whether they have had treatment for a mental disorder. [OBJECTION, YOUR HONOR! RELEVANCE?] If they answer “yes” (and they must answer truthfully under penalty of perjury, they must submit a letter to the bar from their treatment provider describing the nature of their symptoms and course of treatment. Law school is a virtual breeding ground for depression, anxiety, substance abuse, and various stress-related ailments, but many law students will not seek treatment because they don’t want their law careers to be jeopardized by answering “yes” to that question. And I can’t say that I blame them.

• Some adoption agencies, particularly those that deal with international adoptions, categorically refuse to consider individuals who have been diagnosed with or treated for any mental disorder as potential adoptive parents. For example, taking medication for any mental illness, including anxiety or depression, automatically disqualifies hopeful adoptive parents from adopting Chinese orphans. Because, of course, isn’t it better for a child to grow up in an impoverished orphanage without access to modern medical care or higher education, rather than in a loving, stable home with a dad or mom who has responsibly sought treatment for A VERY COMMON, VERY TREATABLE MEDICAL CONDITION? Notably, having an undiagnosed, untreated mental illness does not disqualify potential adoptive parents from adopting Chinese orphans. This policy clearly discriminates against those who have sought treatment.

• Receiving mental health treatment is potentially damaging to a soldier’s military career. This creates a catch-22, because the very act of serving in the military during times of war is a huge trigger for mental illnesses like PTSD, depression, and substance abuse. Few people escape from deadly combat without some mental scars. Yet seeking treatment and risking a diagnosis of a mental disorder is too risky, and too humiliating, for those who have made a career out of protecting and defending our country.

In each of these instances, people who do not seek treatment for their symptoms seem to have a distinct advantage over those who do. For what other disease is it preferable to stay sick than to get healthy? People with mental illnesses who receive good treatment obviously fare better, on the whole, than those who receive no treatment or insufficient treatment. The ultimate irony here is that many people who have been treated for mental illnesses are at least as “mentally fit” as people without mental illnesses, if not more so, BECAUSE they have been through treatment. In general, those who seek out and receive good mental health treatment tend to develop more self-awareness, better coping skills, and a more positive perspective. Certainly these qualities are beneficial to a student, an attorney, a parent, or a soldier.

The National Institute of Mental Health estimates that more than ¼ of American adults suffer from a DSM-IV diagnosable mental disorder in any given year. Further, mental disorders are the leading cause of disability in the US and Canada for individuals ages 15-44. Most upsettingly, only 41% of Americans with diagnosable mental disorders have received any mental health treatment at all in the previous 12-month period. The vast majority of mental illnesses are treatable and manageable – and some are even curable – when the patient receives appropriate care. Imagine how many lives are destroyed, how much productivity is lost, and how much suffering is perpetuated not by mental illness per se, but by people’s refusal or inability to get proper mental health care.

At times, the state of affairs in mental health care looks so bleak that I ask myself why I have chosen this field. My conclusion: the awful state of mental health care is precisely the reason why I have chosen this field. As I ponder this issue, I am reminded of an inspiring quotation from Neale Donald Walsch: “Be a light unto the darkness, and curse it not.” I’m doing my very best to be a light unto the darkness. It’s the “curse it not” that I find much more challenging.

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Posted in Psychotherapy, Psychotropic Medication | 4 Comments »

Wednesday, October 21st, 2009

Reflections from a Rocking Chair

The recent media frenzy over the “balloon boy” hoax has gotten me thinking about the use of the media in today’s society and how it impacts our youth. The explosion of mass media over the past 10 – 15 years, from 24-hour news networks to the internet and email to blackberries and cell phones for everyone, has undoubtedly had a positive impact in many ways. Vital information can be widely disseminated at the click of a button. Parents can keep close tabs on their children. Businesspeople can check their email and voicemail during the metro ride home. Practically anyone can contact anyone else in the world, anytime, from virtually anywhere, using at least two different forms of instant communication. So much has changed since the bygone days of my own adolescence (we’re talking mid-1990’s) that I am beginning to feel like a grandparent on a rocking chair, pontificating about how, back in my day, we had to walk 10 miles to school in the snow uphill both ways.

And then there’s the ugly side. We spend precious time surfing the internet, watching YouTube videos and facebooking and twittering and texting. This is time that could have been spent reading or playing outside or exercising or engaging in a hobby or spending quality time with family and friends. Going a day, or even a few hours, without internet access leaves some people paralyzed. We feel naked without our cell phones; out of touch without instant access to emails. The amount of time we spend chained to various electronic devices continues to increase exponentially to the point where many people can no longer really relax or get away from their work or their social obligations.

My greatest concern about the mass media explosion is the impact it has on youth – their perceptions of reality, their aspirations for fame or recognition, their interpersonal boundaries, their privacy, their sense of what is normal and reasonable and right. I find it disconcerting when a young patient decorates her myspace with pictures of the scars on her wrists or photos of herself at a dangerously low weight. I am frightened when a teenage girl shares intimate details of her abuse history and her multiple psychiatric hospitalizations with her “friends” on facebook. “Everyone does it,” they say. “It’s not a big deal. It’s who I am.” It IS a big deal, I argue. And no, it’s NOT who you are. Therein lies the rub.

A person who presents herself online in this fashion is engaging in a disturbing form of emotional exhibitionism that has proliferated alongside recent technological advances. She is promoting dangerous stereotypes, over-identifying with her illness, and encouraging others to do the same. I do my best to chip away at the silence and stigma surrounding mental illness, and I firmly believe that having depression or bulimia or borderline personality disorder is not something to be ashamed of. But it’s also not something to advertise to a world-wide audience of anonymous viewers with questionable motives. These are issues to be discussed with a therapist, with family members, with a select group of long-time, trusted friends.

I am ambivalent about the proliferation of websites and blogs about personal experiences with mental illnesses. On one hand, as a therapist, I fully appreciate the healing power of writing, sharing, and connecting. Individuals who share their personal stories of psychological disorders with a worldwide audience are providing hope, support, and inspiration to others who are in similar positions, while slowly chipping away at the shame, secrecy, and stigma that continues to surround mental illness.

I frequent several blogs (Carrie Arnold’s ED Bites, Laura Collins’ Eating With Your Anorexic, and Harriet Brown’s Feed Me) authored by individuals who have personally struggled with eating disorders or helped loved ones recover. I admire these authors’ commitment to advocating for improved awareness, understanding, information, and evidence-based treatment for eating disorders. The authors’ personal experiences are interwoven with scientific research in ways that educate, enlighten, and inspire.

On the other hand, I have also read numerous websites and blogs, authored by individuals with mental illnesses, which I can only characterize as glaring emotional exhibitionism. These blogs are not-so-subtle cries for help, yearnings for deeper connection through a superficial medium. I am not quite sure who is benefitting from a young woman’s blog posts detailing her various creative methods of purging or her meager consumption of carrot sticks for days on end. How about writing in a good old fashioned journal? Seeing a therapist? Joining a support group? Calling a friend? Meanwhile, how about developing a healthy identity apart from your symptoms and making real-life friends outside your diagnostic category?

The individuals who use the internet in this way are not the source of the problem. They are the victims of a society that fails to teach appropriate interpersonal boundaries and encourages people to sacrifice their self-respect for a chance at instant notoriety. What happens ten years down the road, when the teenage “cutter” with a provocative personal website applies for a job as a high school teacher? How will this deeply personal, globally publicized information impact the course of her life? Only time will tell. For now, I’ll step away from my computer, get back on my rocking chair, and try to remember what life was like before blogging.

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Posted in Depression, Eating Disorders, Media | 3 Comments »

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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Posted in College students, Psychotherapy | 3 Comments »