Treating Pediatric Bipolar Disorder

by Kelsey Ross, M.A., Guest Blogger

In the United States, at least 750,000 children and adolescents are diagnosed with pediatric bipolar disorder (PBPD) (Killu & Crundwell, 2008). PBPD is a biological brain disorder that causes fluctuations in a youth’s mood, energy, and ability to function (Killu & Crundwell, 2008). PBPD is characterized by a slightly different presentation than the adult presentation of bipolar disorder, yet the adult criteria are used to diagnose children (American Psychological Association [APA], 2013; Grier, Wilkins, & Szadek, 2005). This is one reason why PBPD remains one of the most difficult disorders to diagnose and treat in youth, and under-detection, misdiagnosis, and inappropriate treatment are serious problems (Lofthouse & Fristad, 2004; McDonnell, 2010).

Evidence-Based Treatments

Lofthouse, Mackinaw-Koons, and Fristad (2004) found that pharmacological treatment is often the first step for children and adolescents with PBPD, and it is not uncommon for youth with PBPD to take several medications. Youth are often given a mood stabilizer, followed by a low dose anti-depressant to reduce depressive and anxiety symptoms and/or psychostimulants to reduce ADHD symptoms of inattention, impulsivity, and hyperactivity. These medications may be supplemented by anti-psychotic medications to reduce aggressive or psychotic symptoms and/or anti-hypertensive medications to improve the sleep-wake cycle.

To address the significant impairment in family life, social relationships, academics, and behavior, psychotherapy is often needed (Lofthouse et al., 2004). Psychoeducation, which teaches parents and youth about the disorder, its treatment, and the signs of relapse so that they can seek treatment early, can be an important component of psychotherapy (NIMH, 2012). The major psychotherapy options for PBPD include cognitive behavior therapy (CBT), which helps the youth change harmful thought patterns and behaviors; family-focused therapy (FFT), which teaches the family coping strategies, communication skills, and problem-solving skills; and interpersonal and social rhythm therapy, which aims to improve peer relationships and manage daily routines and sleep schedules (NIMH, 2012). Psychotherapy that combines these approaches can also be effective: one study found promising results for an FFT and CBT combined treatment for PBPD (Pavuluri et al., 2004).

School-Based Interventions

There are currently no research-supported school-based interventions for PBPD (Lofthouse et al., 2004). The pharmacotherapy and psychotherapy discussed do not primarily involve school professionals and would not be appropriate if administered solely in school settings. However, school professionals still play an instrumental role in treating youth with PBPD.

In terms of pharmacotherapy, school psychologists and school nurses can create a behavioral intervention plan that schedules a youth’s medication to be taken during the school day (Grier et al., 2005). This plan increases medication compliance, which can be an issue for youth with PBPD (Grier et al., 2005). School psychologists should also be aware of common side effects of PBPD medications (Grier et al., 2005). Then, school psychologists can include accommodations and modifications that address these side effects in a youth’s Individualized Education Program (IEP) or 504 plan (Grier et al., 2005). For example, one common side effect is frequent urination (Casey, 2006). A school psychologist could suggest an accommodation that allows the child to have unlimited access to the bathroom.

Regarding psychotherapy, school psychologists can supplement the community-based therapy with additional skills training sessions. For example, perhaps a child with PBPD receives Child and Family Focused Cognitive-Behavioral Treatment (CFF-CBT) in the community. Phase three of CFF-CBT teaches the child social and problem-solving skills (Casey, 2006). The school psychologist can collaborate with the community mental health professional to provide a school-based social skills intervention that reinforces the CFF-CBT social skills training (Grier et al., 2005).

Though pediatric bipolar disorder affects 2.2% of U.S. adolescents ages 13 to 18, it is not yet entirely understood (Merikangas et al., 2012). Researchers debate almost everything about the disorder, including the label, age range, prevalence, and risk factors. However, what is not debated is that PBPD can negatively impact students’ academic, social, and psychological functioning. Fortunately, evidence-based treatments exist; however, additional school-based interventions are needed to provide comprehensive support for youth with PBPD.

References:

1. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
2. Casey, K. (2006). Effective interventions for students with bipolar disorder. In C. Franklin, M. B. Harris, & P. Allen-Meares (Eds.), The school services sourcebook: A guide for school-based professionals (119-127). New York: Oxford University Press.
3. Grier, E. C., Wilkins, M. L., Szadek, L. (2005). Bipolar disorder in children: Treatment and intervention, part II. NASP Communique, 34(3), 1-7.
4. Killu, K., & Crundwell, R. A. (2008). Understanding and developing academic and behavioral interventions for students with bipolar disorder. Intervention In School & Clinic, 43(4), 244-251.
5. Lofthouse, N., & Fristad, M. A. (2004). Psychosocial interventions for children with early-onset bipolar spectrum disorder. Clinical Child And Family Psychology Review, 7(2), 71-88. doi:1096-4037/04/0600-0071/0
6. Lofthouse, N., Mackinaw-Koons, B., & Fristad, M. A. (2004). Bipolar spectrum disorders: Early onset. Retrieved from http://www.nasponline.org/communications/spawareness/bipolar_ho.pdf
7. McDonnell, M. A. (2010). Race, gender and age effects on the assessment of bipolar disorder in youth (Doctoral dissertation). Retrieved from Nursing dissertations. (d20000351)
8. Merikangas, K., Cui, L., Kattan, G., Carlson, G., Youngstrom, E., & Angst, J. (2012). Mania with and without depression in a community sample of US adolescents. Archives of General Psychiatry, 69(9), 943-951. doi:10.1001/archgenpsychiatry.2012.38
9. National Institute of Mental Health (NIMH). (2012). Bipolar disorder in children and adolescents. Retrieved from http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-adolescents/Bipolar_Children_Adolescents_CL508_144277.pdf
10. Pavuluri, M. N., Graczyk, P. A., Henry, D. B., Carbray, J. A., Heidenreich, J., & Miklowitz, D. J. (2004). Child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: Development and preliminary results. Journal of the American Academy of Child and Adolescent Psychiatry, 43(5), 528-537. doi:10.1097/01.chi.0000116743.71662.f8

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Kelsey Ross, M.A., is a third year doctoral student in school psychology at The Ohio State University (OSU). She received a B.A. with Honors Research Distinction in psychology and English from OSU. She currently serves as the Social Justice Chair for OSU's Student Affiliates in School Psychology (SASP). Kelsey's research interests include reading instruction and interventions.

Did You Know? Managing Holiday Stress

by Guest Blogger, Nicole Bosse, Psy.D.

The holidays are often the most stressful months of the year. This may surprise some, as many think that holidays bring joy and celebration. Often holidays can trigger many stressful situations, such as trying to figure out how to afford to buy gifts, remembering loved ones who are no longer here to celebrate with us, mingling with family members when relationships are strained, taking on too many duties, and preparing a home for guests.

There are several different types of stress that range from Eustress, which is a positive form of stress, to chronic stress, which has been linked to many serious health issues. While we want to manage or eliminate the negative types of stress, we also want to keep positive forms of stress in our lives to help us remain vital and alive.

To eliminate negative stress identify techniques that relax and energize you, have immediate impact on your stress, are enjoyable and make you feel good, consistently work for you, and are always or easily accessible. One of the best ways to reduce stress quickly is through the senses: sight (look at a cherished photo), sound (listen to nature), smell (light a scented candle), taste (sipping hot tea), touch (petting cat/dog), and movement (running in place).

In addition, here are five quick ways to cope with feeling overwhelmed during the holiday season:

• taking a brief walk to clear your mind
• practicing deep breathing
• partaking in guided imagery
• reframing the situation
• delegating tasks
• engaging in progressive muscle relaxation.

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Dr. Bosse is currently a Post-Doctoral Fellow on the OCD and Anxiety team at the Lindner Center of HOPE. She primarily provides treatment on the two residential units, Sibcy House and William’s House. Dr. Bosse obtained her doctorate in Clinical Psychology at Xavier University in 2014 and her Master’s in Clinical Psychology at the University of Dayton in 2009.Prior to joining the Lindner Center of HOPE, she completed her APA accredited internship at the Wright State School of Professional Psychology. Dr. Bosse has also served as adjunct faculty at Xavier University for several Introduction to Psychology courses.

 

OCD: Treatment via Support Groups

By Guest Blogger Beth McCreary, Ph.D.

Support Groups for OCD

I appreciate the opportunity to share some information on OCD and Support Groups.  I’ll first summarize some information on OCD and its treatments, then share the information about OCD Support Groups.

Obsessive compulsive disorder (OCD) affects approximately 1.2% of the population of the United States in any given year.  Those living with OCD experience intrusive thoughts, images, or urges that they find distressing and do not want to be having (“obsessions”), and from which they can sometimes gain temporary relief by engaging in overt or covert ritualized behaviors (“compulsions”).  However, engaging in compulsions can consume enormous time and energy, and, across the long term, actually perpetuates obsessive thoughts and associated anxiety.  The experience of OCD can range from frustrating and mildly interfering in quality of living to completely disabling.  OCD has strong genetic and other biological correlates, and tends to be episodic across the lifetime when effective treatment is not obtained.  Even with treatment, intrusive thoughts may continue to occur but do not have to interfere with quality of living once a person learns to respond to them differently (without rituals).

Effective treatments for OCD include exposure with response prevention (ERP, the “gold standard” behavioral intervention) and medication management.   ERP involves coming into contact with various triggers of obsessive thoughts (i.e., the “exposure”), then allowing oneself to feel anxious instead of trying to alleviate the anxiety by ritualizing (i.e., the “response prevention”).  Cognitive and mindfulness strategies are often helpful in conjunction with these treatments.  Obsessive thoughts are often viewed by the person experiencing them as evidence that s/he is morally bad, dangerous, or insane.  Cognitive intervention for OCD focuses on correcting these misattributions for obsessive thoughts.  Mindfulness practices can help people observe the body sensations of their anxiety and distress with acceptance instead of judgment, and focus on the task at hand while resisting the urge to ritualize during ERP, for example.

Jonathan Grayson, PhD, a leading authority on the treatment of OCD, and Gayle Frankel (President of the Philadelphia Affiliate of the Obsessive Compulsive Foundation at the time) began a support group for sufferers in Philadelphia over 30 years ago with the purpose of trying to prevent relapse in people who had undergone treatment for OCD.  With experience, they learned that dividing the group into three segments provided a necessary and productive structure.  The GOALS Group (Giving OCD-Sufferers Another Lifestyle) begins with a period of discussion of a topic related to OCD, then moves to a time for each attendee to plan a specific task to practice (e.g., a ritual reduction and/or an exposure) between groups, and ends with a period of completely social time for conversation and connecting.  That original group survives today, and has been the inspiration for many other groups across the country.  (See the Handbook for their GOALS group, here:

  https://iocdf.org/wp-content/uploads/2014/08/OCD_GOAL_Manual.pdf) 

I started the Worthington, Ohio (northern suburb of Columbus) GOALS group in January 2013 and facilitate it twice per month.  We are a little broader in our goal-setting portion of the group, encouraging not only ERP tasks but also mindfulness strategies, self-monitoring of symptoms, and exercise or other forms of self-care—essentially anything specific that a person can work on to have a positive impact on his/her OCD.  Participants are encouraged to tell their stories, to support one another, and to actively choose to behave according to what they value in life rather than what the OCD “tells” them to do.  (If you are familiar with Acceptance and Commitment Therapy, you can probably see how this combination of mindfulness of emotional and cognitive experience coupled with value-based behaving fits very well with ERP.)  Our GOALS group offers a combination of education and encouragement (not only from the facilitator but more importantly from participants with experience living with OCD), and supportive connections with others who truly understand how frightening and frustrating it can be to live with this brain condition.  Some participants come regularly, others occasionally, but almost all have commented that they have found it valuable both to be understood and to have reinforcement (and sometimes new information) regarding strategies for combatting OCD.  The group is intended as an adjunct to, not a replacement for, psychotherapy.

No direct referral is necessary.  Anyone age 18 and up who believes s/he has OCD is welcome to simply show up.  There is an informed consent form explaining some group parameters that is given to each attendant at the first visit.  For details on the time and place of the group, check the Mental Health America Franklin County (our sponsor)’s website, here:  http://mhafc.org/get-help/support-groups/ocd/

For much more information on OCD and its treatment, see the International OCD Foundation’s website, here:  https://iocdf.org/

For a terrific self-help book on OCD (also a wonderful learning resource for practitioners), see Dr. Grayson’s recent book, “Freedom from Obsessive Compulsive Disorder,” Updated Edition, 2014:

http://www.amazon.com/Freedom-Obsessive-Compulsive-Disorder-Updated/dp/042527389X

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Beth McCreary, PhD, is a psychologist in her own private practice (Anxiety and Behavioral Health Services) in Worthington, Ohio.  She specializes in cognitive and behavioral interventions for anxiety disorders, and incorporates elements of mindfulness and acceptance and commitment therapy into her work.  Dr. McCreary obtained her doctorate from The Ohio State University (OSU) and completed postdoctoral work that included clinical training from the Anxiety and Stress Disorders Clinic at OSU as well as a research component through Johns Hopkins University.  She has presented on the treatment of anxiety disorders to other practitioners and does some individual consulting as well.

5 Ways To Boost Clients' Life Satisfaction by Using Their Religious Values

by guest blogger, Tara Luchkiw, M.A.

Numerous research studies have demonstrated that there is a positive relationship between religiousness and psychological well-being (Koenig, 2001). People who report having strong religious belief and engaging in frequent religious behaviors often report higher levels of satisfaction with life and lower levels of anxiety and depression than those who report infrequent attendance at worship services, sporadic private prayer practices, and doubts in their beliefs. Several researchers have proposed a number of reasons why religious behavior might be related to greater well-being. Likely explanations include the provision of social support, establishment of meaning in life, engagement in healthy lifestyle choices, promotion of positive religious coping styles, and facilitation of positive affect, all of which are believed to be endorsed by and facilitated through religion (Ellison, Boardman, Williams, & Jackson, 2001; Ellison & Levin, 1998; George, Larson, Koenig, & McCullough, 2000; Seybold & Hill, 2001). Addressing these components in treatment can assist your clients with engaging in value-driven behaviors. 

Many clients look to their religious faith to give them strength and hope as they work through various psychological difficulties. For these clients, integrating their personal beliefs into treatment may lead to better treatment outcomes. For example, in a review of studies examining religion and mental health, depression in patients treated with religious interventions was resolved more quickly than in patients treated with a secular intervention or no intervention in five out of eight clinical trials (Koenig & Larson, 2001). The following are five ways you can engage your clients’ religious values in treatment.

1. Encourage your clients to get more involved in activities at their place of worship or to attend services more regularly. Religious involvement provides access and opportunities to create social networks with people who share similar values, morals, interests, and activities. A large social support network could provide emotional and tangible assistance that may promote better mental health among religious persons. Consider suggesting church-based activities as behavioral activation targets.

2. Encourage your clients to establish a daily practice that includes private prayer or devotional activities. Religious belief provides a view of the world that gives experiences meaning, which yields a sense of purpose, direction in life, and peace of mind for the believer. One study found that participants reported having a greater sense of meaning in life and greater well-being on days that they engaged in religious behaviors (Steger & Frazier, 2005). The findings from this study also suggest that religious individuals feel greater well-being because they derive meaning in life from their religious activities. Consider implementing mindfulness meditations in the form of private religious devotional practices.

3. Focus on client beliefs that prescribe healthy lifestyles. Many religious faiths teach members to respect and care for their bodies. They teach, for example, that the body is the temple of God, or that life and health are gifts that are deserving of gratitude and responsible stewardship. Consider using such client values to guide treatment goals for engaging in increased healthy behaviors.

4. Explore religious coping techniques. Clients may reference their religious beliefs in various ways in attempt to cope with difficult life situations. Some forms of religious coping may be healthy and adaptive, whereas others may be negative and maladaptive. Consider exploring with a client the ways he or she uses religious beliefs to cope, and whether the clients’ current coping patterns are effective.

5. Focus on aspects of religious faith that promote positive emotional experiences, such as hope, gratitude, grace, and forgiveness. Some religious clients may struggle with intense experiences of guilt, shame, or fear of divine punishment. These are areas the client may wish to discuss with a religious leader. In such a case, a referral to a pastor, priest, rabbi, etc. may be appropriate.

Like all other aspects of diversity, religious belief and behavior is an important domain in which psychologists should seek to develop competence. Individuals may express their faith differently from other members in the same religious category or denomination. Thus it is important to discuss each client’s religious values from his or her perspective. It is not necessarily the case that a treatment provider must share the same religious beliefs and values as the client, however it is essential that the provider approach a client’s faith with sensitivity and respect. Doing so with a competent integration of religious activities in treatment has the potential to enhance client well-being and overall treatment outcomes.

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Tara K. Luchkiw, M.A. is a doctoral student in the Clinical Psychology program at the University of Mississippi. She is currently working on her dissertation and will be applying for her predoctoral internship in Fall 2014.

Full reference citations available upon request
 

Need Resources? Try 211

by Guest Blogger, David Weaver, Ph.D.

Clients Over-Whelmed? You Over-Worked? Call 211 or Search 211.org

Does your clint have multiple unmet needs? Like food, shelter, health care, transportation, child care, recovery from addiction or other problem. Would you feel over-whelmed? Could you effectively and simply help them help themselves?

Calling 211, or going to 211.org or 211franklincounty.org (Hands On Ohio in FC) gets the person the necessities they need. They get them for themselves. Its sponsored by the United Way and Alliance of Information and Referral Systems (nationwide). The person quickly learns about self-help groups, self-reliance, and all community services.

The new psychologist in a community mental health agency working with addicted, alcoholic, homeless, physically ill, felons, suicidal or homicidal clients has backup. Simply refer those pesky non-treatment plan issues to 211. The professional also learns by exploring 211.

I have been strengthened and calmed by knowing 211 had my professional back. It discharges my counter-transference (especially when I use self-reliance groups like Al-Anon) and my liability. Referral to the professional 211 agency allows the person to decide what to do and with which resource. It works for my clients multiple problems, allowing us to focus on psychotherapy and helping all of us to feel better. I sleep better.

People using 211 gain motivation, remission and recovery. They are more likely to help themselves solve their problems.

Self-help groups are the third pillar of treatment. They boost the effect of psychotherapy and medicine. They are infinitely expandable having the capacity to divide like a cell and serve all 3 million diagnosable Buckeyes. For free and with around the clock coverage given their use of sponsors and phone numbers. Peers helping peers are motivated and knowledgable. They are always available. The meetings are always available. They target their issues with great fidelity. When wo recovering people are welcomed, accepted and respected, we heal. Self-reliance also heals.

211 began in 1979 (the 'community' mental health promise, since broken). But, according to my small sample surveys only a consistent 20% of police, physicians, counselors, teachers, and State employees know what 211 is. Let us get 80% educated about 211. Get the 411 on 211. Refer to it.

Call 211.

211.org

211franklincounty.org

Guest Blogger: "They" can be "Us"

by Guest Blogger: Morgan Shields 

America is a place that fosters individualistic pride. But this sense of independence is an illusion. We are not actually independent. As social creatures, our mental and physical health depends upon the support and acceptance of our community and society at large.  We need each other for social support, but also services. We need doctors, teachers, and farmers to provide services that we cannot produce on our own.  We need our neighbors to call 911 when we fall off of a ladder, and we need doctors to “fix” the broken bones.  We need the police to investigate when we are mugged, and we need our friends and family to support us after the trauma.

Can you imagine a society without a cooperative system? Can you imagine living in a world where everything is a cut-throat competition; where the only person you could depend on was yourself?  If you can imagine this, I am sure you can also imagine how short-lived the human race would be in such an environment.

But this is what we expect from each other and ourselves. We expect others to be tough and able, and if others are not tough and able, then that means they are not “good enough.” Further, since we expect ourselves to also be tough and able, we experience shame in asking for help, because we fear appearing weak.

What sickness and stigma this fosters.

Nobody can be tough and able all of the time. We all have our moments of need. Yes, some require more support than others, but this is rarely their fault. People do not give themselves depression on purpose. Or bipolar disorder. Or autism. Or homelessness. People do not make a decision to acquire these struggles and differences. People do not choose to be born into poor families, grow up in foster care, or to be the child of a parent who used drugs during pregnancy. People do not elect to get cancer, traumatic brain injury, or multiple sclerosis. It happens and it can happen to any of us. In fact, it is likely that we will experience severe illness – whether mental or physical – at some point in our lives.

What is amazing about the people of this world is that we are all different. Every single person has had an accumulation of different experiences and perceptions that make them who they are. In recognizing this, we can then realize the uselessness and underlying ignorance in passing judgments.

Judging another’s situation is not going to serve anyone well. Contrary to a competitive mindset, another’s misfortune does not make you a better human.

What we all should be aware of is that tomorrow we can be the person sleeping on the street. We can have a psychotic break. We can get into a car accident, hit our head, and experience a change in personality. These things can happen tomorrow. My objective is not to instill fear, but to engender gentleness in our interactions with the world, our thoughts of people and their labels, and our perceptions of our true independence and dependencies.

We need to end the stigma of mental illness and difference. It is the stigma that keeps people from reaching out for help. Mental illness needs to be normalized and accepted. This needs to happen at all levels of society. We need to educate people about mental illness without dichotomizing the “ill” from the “sick.” Creating otherness does not help. Otherness perpetuates stigma. Further, perhaps there would be decreased rates of anxiety and depression if there was not so much pressure to be tough and able. We are not naturally built to operate in this way. It is not healthy.

It is my hope that we can all learn to be gentler with ourselves and with each other. We have all been born into different situations and have had different experiences. While it is great to have pride in one’s merit, our worth should not be dictated by our accomplishments and ability.

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This post is in honor of Mental Illness Awareness Week (October 6-12, 2013). It's time to speak out. 

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Morgan is currently a senior at Kent State University, majoring in psychology. Prior to college, she served in the AmeriCorps National Civilian Community Corps, where she traveled the country working for various non-profits and government agencies. During her service, she interacted with the homeless population on a regular basis, and saw our system’s failure in the lives of these individuals. Once she started college, she began working as a Research Assistant in the Clinical Neuropsychology Laboratory, under Dr. Mary Beth Spitznagel, and the Emotion, Stress, and Relationships Laboratory under Dr. Karin Coifman. She has numerous research presentations under her belt, as well as several manuscripts in the works. This past summer, Morgan was awarded a research fellowship by the National Science Foundation to study under the mentorship of Dr. Richard Davidson at the University of Wisconsin – Madison. While there, she was exposed to research projects that focused on cultivating compassion and empathy. Currently, Morgan is applying for a Fulbright scholarship, to study at the University of Waterloo, in Ontario, Canada. If awarded the Fulbright, her project will focus on investigating how the occupational culture of staff workers within acute psychiatric facilities influences the staff-patient relationship. She will collect perspectives from both staff and patients, and hopes to elucidate the enormous value of patient-perspectives. Morgan plans to continue her education and research at the PhD level in a program where she can focus on studying mental health care and stigma.

Guest Blog: Mental Illness and Quality of Care

by Guest Blogger Morgan Shields

Mental illness impacts all sectors and populations across the globe, and exacts heavy costs with regard to both economic and human suffering. However, our mental health care systems do not effectively treat individuals; this is especially true at the acute level. During the 1970s, there was a global deinstitutionalization of long-term-stay mental health care hospitals. With increased effectiveness of psychotropic medication, patients were better able to function independently through the support of outpatient community services. What remains are acute psychiatric wards of hospitals, which largely serve as a stabilization hub for patients who pose a threat to themselves or the community, with the typical stay lasting between three to seven days. Additionally, social workers and providers sometimes work to connect these patients with community services upon discharge, to ensure they receive appropriate long-term treatment. 

However, the experience one has within these wards, and upon discharge, varies drastically depending on insurance, location, and even the occupational culture of the ward. Furthermore, whether patients seek out community services upon discharge is largely dependent upon their ability to pay for these services and their trust of the system.   

While there are many contributing factors to the quality of care within acute psychiatric facilities such as funding mechanisms, policy, and location, it has been suggested that the staff-patient relationship is potentially one of the most important moderators of patients’ perceptions of quality of care and treatment outcome. This makes intuitive sense, as patients interact with the staff workers more than they do anyone else; meetings with a psychiatrist last only two to fifteen minutes a day. The occupational culture of staff workers, or their shared beliefs and norms, shape the way the staff interact and view patients. 

This, of course, is also influenced by the overarching culture of the administration and hospital at large, and also by the patients’ behavior. Additionally, there are no standardized credential-requirements to work within these wards; therefore, some places have workers who lack necessary training, and often carry a good deal of stress due to being underpaid and overworked.

Currently, investigation of psychiatric wards is sparse, with very little integration of patients’ perspectives.  Such lack of input from patients is disconcerting, as these individuals are the sole consumers of this care. Therefore, their insight into the treatment experience should be of unique value. However, it is the unfortunate case that patient-perspectives are not valued at the research level as much as provider and nurse feedback; this is largely due to the stigmatic belief that patients lack insight. This outdated and extreme view only works to oppress individuals who find themselves in need of such services, as it prevents them from having an active voice in the treatment process and to be taken seriously when possible mistreatment is at-hand. Furthermore, it sends the message that society views these individuals as problems to be taken of, rather than humans in need of help and sensitivity, and creates a divide of “us vs. them.”  

I am currently working on a project where I collect personal testimonials from former patients. There are common themes of invalidation throughout the experiences I have listened to and received. One woman stated that she felt like she was treated like a prisoner during her stay on an acute psychiatric ward, and eventually started to view herself as a bad person being punished, instead of a sick person receiving treatment. She explained that she did not have insurance at the time, and was therefore transported to a state–ran facility.  When she arrived, she immediately felt like a prisoner; there were many rules, she could only use the phone for a few minutes a day, and most of the staff workers ignored her concerns. She was never told what type of medication she was on, and when she tried to refuse medication, she was threatened to be restrained and put into a locked room alone. 

Without much choice, she ended up taking the medication, even though it made her ill and eventually paralyzed her neck. It was only when her neck was paralyzed that the staff listened to her complaints by adding a countering medication to her cocktail. After she was discharged, she struggled to rebuild her sense of self and trust of the mental health care system. This story exemplifies disconnected, demoralizing, and dehumanizing aspects of a mental health care system intended to heal. This is not the affect these places are supposed to have on people; it is counterproductive and has serious ethical concerns.

Of course, there are many staff workers and nurses who work their hardest to maintain compassionate interactions with patients, and I don’t mean to insult their efforts. This is not meant to serve as a blanket generalization of the entire system. There are effective and humane wards that serve the community well, but there are also units that have the potential to do more damage than good, and these should not be overlooked. It seems clear that there needs to be more attention given to acute psychiatric care, with an emphasis on increasing its quality and humanity. There needs to be more research of not only patients’ lived-experiences, but also further investigation of staff workers perceptions of their responsibilities and role within the hospital system, in order to better understand the complex interplay between the hospital, administration, staff, and patients. 

I personally believe that stigma underlies most of the disconnect we see within these wards. It is not only the staff workers who can sometimes view patients through stigmatic lenses, but it is also the providers and the community at large. As a society, we have been conditioned to view suffers of mental illness to exist on the periphery of what we consider worthy of acceptance, respect and love. Therefore, not only can a change in policy improve conditions, but so can a change in culture. The latter may be the hardest part to change, but it can be done with time, persistence, and openness. 

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Morgan is currently a senior at Kent State University, majoring in psychology. Prior to college, she served in the AmeriCorps National Civilian Community Corps, where she traveled the country working for various non-profits and government agencies. During her service, she interacted with the homeless population on a regular basis, and saw our system’s failure in the lives of these individuals. Once she started college, she began working as a Research Assistant in the Clinical Neuropsychology Laboratory, under Dr. Mary Beth Spitznagel, and the Emotion, Stress, and Relationships Laboratory under Dr. Karin Coifman. She has numerous research presentations under her belt, as well as several manuscripts in the works. This past summer, Morgan was awarded a research fellowship by the National Science Foundation to study under the mentorship of Dr. Richard Davidson at the University of Wisconsin – Madison. While there, she was exposed to research projects that focused on cultivating compassion and empathy. Currently, Morgan is applying for a Fulbright scholarship, to study at the University of Waterloo, in Ontario, Canada. If awarded the Fulbright, her project will focus on investigating how the occupational culture of staff workers within acute psychiatric facilities influences the staff-patient relationship. She will collect perspectives from both staff and patients, and hopes to elucidate the enormous value of patient-perspectives. Morgan plans to continue her education and research at the PhD level in a program where she can focus on studying mental health care and stigma. 

Bullying

Bullying
Article by Guest Blogger, Kimberly Burkhart, Ph.D.

Bullying is a relationship-based form of aggressive behavior, which involves the use of repeated intentional acts to humiliate, dominate, and oppress others.  There are four types of bullying that are most common among children and adolescents:  Verbal, physical, relational/social, and electronic.  

The 2009 Youth Risk Behavior Survey indicated that 20% of students had experienced some form of bullying in the previous 12 months.  Moreover, research suggests that 10-40% of youth reported being victims of some form of electronic bullying.  Bullying is associated with increases in suicide risk, depression, irritability, anxiety, sleeping difficulties, somatic problems, violent behaviors, and higher rates of school absenteeism among victims.  

Children who have special healthcare needs, specific language impairment, learning disabilities, pervasive developmental disorders, co-morbid psychiatric problems (internalizing and externalizing disorders), and those who have identified or who are perceived as being part of the LGBTQ community are more likely to be the victim of bullying.  

Some signs that a child may be bullied include unexplainable injuries, destroyed property, changes in eating habits, decline in academic performance, decreased self-esteem, avoidance of social situations, and engaging in self-destructive behavior.  

Some signs that a child may be bullying others include getting into physical or verbal fights, acquiring new belongings that are unexplainable, increasing aggressiveness and competitiveness, and blaming others for his/her mistakes.  

For more information on how to prevent or respond to bullying, please consult www.stopbullying.gov.

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Kimberly Burkhart, Ph.D. is a Clinical Child Psychology Fellow at Nationwide Children’s Hospital.  She is the Chair of the Ohio Psychological Association’s Bullying Prevention Task Force.    

Successfully Empowering Male Survivors of Sexual Victimization to Thrive

Successfully Empowering Male Survivors of Sexual Victimization to Thrive

a guest post by Howard Fradkin, Ph.D.


Male survivors face special challenges to achieve mental health, and the good news is it is possible and achievable to overcome these challenges and help them not only survive and heal, but to actually thrive.  As a Psychologist, we have an incredible opportunity to be agents of change for these men and those who love and support them.


One in 6 men has been sexually victimized by the age of 16, according to social science research (www.jimhopper.com) One in 8 rape victims is a man.  These statistics represent an epidemic of silence that has the potential to severely damage the lives of boys and men who do not get help.  We've all heard about the recent scandals:  Jerry Sandusky, the Catholic Church, the Boy Scouts, even Sesame Street.  It seems once a week our local papers have yet another article about the crimes being committed against boys and girls.  But often, by virtue of language, "abused children" does not translate to boys in many people's minds; they think about the girls.  Without minimizing the horrendous crimes done to 1 in 4 girls, we must as a society wake up to the huge numbers of boys and men who are also being victimized.


Typically, male survivors face many mental health challenges, including depression and suicidality, anxiety disorders, damaged self esteem, impaired ability to embrace masculinity, difficulty with trust and forming intimate relationships, and engaging in addictive behaviors including alcoholism, substance abuse, sex addiction and gambling.  Many of these illnesses are rooted in the deep shame that male survivors bury deep inside their souls, fearful for anyone to know the truth of what was done to them.  Survivors of course are even fearful of telling us!  And truthfully, many of them do not even know about their own abuse, or have suppressed so deeply in their bodies, minds and souls, that they are not able to connect the dots between their current dysfunction and the betrayal of their bodies years, maybe even decades before.

Treatment is now readily available in many communities thanks to the training efforts of MaleSurvivor.org and 1in6.org, and our own Ohio Psychological Association.   MaleSurvivor and 1in6 are very important resources for any of your clients who do identify as survivors.  They host extensive websites that offer chatrooms, bulletin boards, articles, bookstores, and access to support groups and psychotherapists who can all provide help.  

Have you received specific training in working with male survivors?  There are significant differences, including the most important:  your recognition that men can indeed be survivors of sexual abuse.  I am amazed at how many male survivors I have worked with who have been to therapy for years, but were never asked the right questions that might have led them to uncover their shameful secrets of being abused.  True, some of them were not ready to talk, but I am convinced that many of them were giving lots of signs to their therapists about their histories, but because the right questions were not asked, they chose not to walk down that path either.

Men are especially vulnerable to male socialization which teaches many destructive messages that must be unlearned in order to heal.  The most significant of these messages are: Men must be strong and tough; men who ask for help are weak; men should always be in control and if they are abused, it is a sign of their weakness.  Thankfully, in our profession, we are skilled at helping men who seek therapy learn how to honor their courage and strength in seeking help for their problems.  Men need a great deal of reassurance that it is okay to talk about abuse, and that you will not judge them.  Too often, men are afraid they will hear from their therapist that they should have been stronger, or should have told someone instead of hiding and burying the secret.  And some are afraid they'll be labeled as perpetrators, or presumed they will become perpetrators simply because they were victimized.

I believe that healing is a process of learning to be disloyal to dysfunction and loyal to functionality.  Each of these damaging dysfunctional messages must be challenged, not just intellectually, but emotionally and physically as well.   Men can be helped to be loyal to functional messages such as:  it is a sign of strength for a man to courageously face the truth of his abuse; men who ask for help will become stronger and more effective and more loving; men can recognize they have zero responsibility for the abuse done to them and that the shame of these actions belongs to the perpetrator who hurt them.  Too often, survivors feel loyal to the perpetrator, and hold on their shame instead of finding ways to release it.  Men can learn to stop choosing to be loyal to dysfunctional ways of coping, such as alcoholism, drug addiction and sex addiction.  They need our support, and they need the support of other male survivors and loved ones to help them overcome their blocks to functionality. 

If you work with male clients, think about the real possibility that 1 in 6 of these men are survivors.  How many are we missing?  

Male survivors need to hear a message of hope.  I for one believe it is ethical and responsible to tell survivors they can survive, they can heal, and yes, they can thrive.  Men need to hear this message of hope.  Too often I think therapists are so cautious that the message male survivors hear instead is, this is a life sentence... it will get better, but you will always suffer from the effects of your abuse.  I am not suggesting we be Polyanna, and tell them it is easy and simple to heal.  Far from it...it is a journey, one with lots of bumps in the road; and many brothers and sisters who will identify, who will offer help, and who really will understand.  I hope you will join forces with me and be a beacon of hope for the 1 in 6 men abused as children and the 1 in 8 adult rape victims who is a man.


Howard Fradkin, Ph.D., LICDC has counseled over 1000 male survivors in individual, couples, group psychotherapy and weekend workshops over the course of his 30-year career as a Psychologist. As Co-Chairperson of the MaleSurvivor Weekends of Recovery, (www.malesurvivor.org) he has co-directed 40 Weekends of Recovery since 2001 for over 880 men. Dr. Fradkin has also trained hundreds of professional colleagues. Dr. Fradkin’s first book, Joining Forces: Empowering Male Survivors to Thrive, was recently published by Hay House in November, 2012.  He is the Co-Founder of Affirmations: A Center for Psychotherapy and Growth, in Columbus.

Guest Blogger: Managing Chronic Pain

by Guest Blogger, David Schwartz, Ph.D. 

One of the few advantages of getting older is the ability to say “”I remember when…”

In 1982 when I did my first clinical placement in pain management, the “state of the art” was that focusing on the patient’s self-report of pain was worthless. Research showed that 0-10 pain scales varied widely between individuals, had little relationship to pathophysiology, and were highly dependent on psychosocial factors.  The emphasis in the field was on the measurement and change of pain behavior  i.e. measures of function such as uptime, days off work, walking tolerance, etc. A parallel theme was that the use of opiates and aggressive medical interventions such as nerve destruction surgery and nerve blocks for chronic pain management were ineffective and counterproductive.  Use of opiates led to decreased function, and withdrawing patients from opiates in the context of a psychological/physical re-activation model (A pain rehabilitation program) consistently increased function. These pain programs remain today as the most effective documented intervention to improve overall life functioning for individuals who had become disabled due to pain.

Fast forward to 2011. These structured pain rehab programs are essentially extinct, starved to death by insurers who saw them as too costly. A patient coming to a pain clinic will almost always be placed on opiates, and receive multiple interventional treatments.  The cost of pain treatment has skyrocketed, yet outcomes are worse.  Prescription opiates are now the most commonly abused drugs, and many states (including Ohio) are launching expensive initiatives to get the ”drug problem” under control.  Worst of all, when the patient returns for a follow-up visit, the only question they are asked is “how is your pain”?

I recently attempted to survey the literature as to whether there was any new evidence that opiates improved function in chronic pain.  What I found was- NOTHING!  It was exceedingly rare to find a study that even measured function whatsoever! (Keep in mind that many studies have shown that patient self-report of function is both reliable and valid, and there are many brief instruments that assess function with documented validity). The studies employed NONE of them. The few studies I did find showed that opiates produced decreases in self-reported PAIN, but no change in FUNCTION.

“The emperor has no clothes”- remember the fable?  Is it possible that the multi-billion dollar pain management industry is a sham? That we are doing worse than we were 30 years ago?

What can we do today?  To me, the crucial thing is to go back to function as the core measure when we deal with pain. Always ask- what are doing that you weren’t doing last session? Are you on your feet, talking to people, cleaning the house more, etc? If opiates are used, are increases in function observed? 

I tell a joke in talks about pain- the punchline is that the patient had pain that was 10 of 10 and lays on the couch in misery all day. His doctor puts him on OxyContin- he comes back and says “it’s a miracle! My pain is 1-2 out of 10! My life is so much better!”  When asked what he now does, he says, “Well, I’m so stoned on the medication I lay on the couch all day…” 

Online Pain Resources:

http://www.ampainsoc.org/resources/clinician1.htm
http://www.nationalpainfoundation.org/articles/469/psychology-of-pain

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Bio: Dr. David Schwartz earned his Ph.D. from Vanderbilt University in 1982, specializing in behavioral medicine, and was an intern and post-doctoral fellow at the University of Virginia Medical Center. He has had medical school appointments at the University of Virginia, Vanderbilt University, and the University of Cincinnati. He has published and presented extensively in pain management and behavioral medicine. He has been in private practice since 1995 and is currently a partner in Hamilton Health Associates, a multi-specialty practice focused on industrial injury.   He is a consultant to the Freiberg Spine Institute and a member of the Disability Evaluation Panel for the Ohio Bureau of Worker’s Compensation (BWC). He presently serves as the Ohio Psychological Association (OPA) representative on the BWC’s Health Care Quality Assurance Advisory Committee and chairs the OPA Task Force on Workers Compensation Reform.

Social Responsibility for Psychological Public Statements Made by Non-Psychologists

by Guest Blogger, Kevin Arnold, Ph.D. ABPP

Social responsibility is a broad term, defined on Wikipedia as “ethical ideology or theory that an entity, be it an organization or individual, has an obligation to act to benefit society at large. This responsibility can be passive, by avoiding engaging in socially harmful acts, or active, by performing activities that directly advance social goals” (Wikipedia). Psychologists act socially in both passive (e.g., decline to advise on effective torture methodology) or active (e.g., deliver behavioral programs to increase child car restraint use by parents) ways. For some psychologists, the opportunity to benefit society is ever present, such as when a psychologist writes for the public media. This blog provides three tenants regarding socially responsible public statements when confronting pseudo-psychology in the media or press.

Claim Our Expertise. We psychologists have clearly defined expertise in the application of psychological constructs and research to everyday problems. We helped developed highly effective prevention programs for health, such as the smoking cessation program at the University of Rhode Island (e.g., Stages of Change), and regularly advise courts on issues ranging from parenting to violence potential. Unfortunately, non-psychologists lay claim to our constructs and theories when they write or make public statements as if experts on clearly psychological topics. Sometimes those writings or statements are benign, while at other times they can create the opportunity for harm. When the latter occurs, we must lay claim to our field, and take an active stance that our education, experience, and training give us unique capacity to apply psychology that others simply do not have. If psychologists fail to own our field, we could both lose our identity and allow pseudo-psychology to harm society. 

Provide Reasonable Alternative Ideas. Far too often, non-psychologists (and sometimes psychologists) overstate the validity of psychological theories in media statements. For example, I have often heard attorneys say that witnesses will not admit to something that is against their interest unless the admission is true. Several psychological theories exist to explain the motivation to meet a task demand under stressful conditions. For example, suggestibility theory argues that false ideas can be implanted through leading questions or exposure to non-factual narrative descriptions. Drive reduction theory (most recently captured in Barlow’s concepts of escape and avoidance) explains efforts to reduce stress cause counter-intuitive behaviors (ala the Milgram experiments). Functional behavior analysis would argue that statements against one’s interests can function to provide social attention and rewards even when such statements are not true. Socially responsible psychologists have an obligation to actively inform the public of these alternatives to thwart the mis-perception that theory is truth, when in fact theory is but plausible explanation of data. 

Correct Mis-representation of Psychological Research. Books, published articles, and media statements often rely on psychological research, or sometimes junk-science masquerading as psychological research, to appear authoritative. In my own experience, the articles and book by the “Tiger Mom” argued that research findings validated her claim that the majority of Asian parents in Asia used, essentially, authoritarian parenting while parents in the United States used overly permissive parenting. She further argued that research showed that her “Tiger Parenting” produced better academic outcomes. However, research specifically on the topic provided findings often either more equivocal than her statements or contradictory to her position. When psychological research is mis-represented, we must actively correct the errors in public statements. Psychologists have a social obligation to protect society against the mis-use of our research so that evidence drives public policy, not pseudo-science.

A Final Thought. I remember former president of APA, Ted Blau, once saying that graduate school often left psychologists with little self-confidence, and without the skills to speak authoritatively. He might have been right; and if so, many of us avoid or ignore the mis-use of psychology by others. But, our education is extensive, our experience accumulates knowledge, and our training is well-supervised. We learn psychological theory, social science statistics, complex research designs, and clinical application methods. Psychologists, most of all, speak with authority on psychology’s role in addressing social problems. Socially responsible psychologists strive to be heard over the din of talking heads and pundits who sometimes use our field to serve their own self-interests.

Ohio Psychologist Blogger on Psychology Today

Check out The Older Dad Blog on Psychology Today, written by Ohio Psychologist Kevin Arnold, Ph.D., ABPP! Dr Arnold is the director of the Center for Cognitive and Behavioral Therapy in Columbus, Ohio, and a licensed psychologist. Kevin is a clinical faculty member in the Department of Psychiatry at Ohio State University, as well as serving a number of leadership roles at the state and national level in cognitive-behavioral therapy and professional psychology. He will be a guest blogger for us in the near future, stay tuned!