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What to know about psychiatric residential treatment

What to know about psychiatric residential treatment
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residential centerHave you been searching for psychiatric residential treatment for your child?  Do all the programs sound wonderful?  Ads include quotes from happy parents, and lovely photos and fabulous-sounding activities.  But what’s behind the ads?  Residential treatment programs are diverse, but there are important elements they should all have.  Here’s how to avoid low quality residential treatment.

Psychiatric residential treatment is serious stuff–it’s difficult to do–especially when troubled children and teens are put together in one facility.

Should you ask other parents for their opinion of a program?  In my experience with a child in psychiatric residential care, and as a former employee of one, word-of-mouth is not the best way to assess quality or success rate.  There are too many variables: children’s disorders are different; acuity is different; parents’ attitudes and expectations are different; length of time in the facility is different; what happens once a child returns home is different…  It’s most helpful to ask questions of intake staff and doctors or psychologists on staff.  Quality psychiatric residential care facilities have important things in common.

What to ask about the staff:

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  • What is the training and licensure of staff?  Are there therapists with MSW degrees, registered nurses, psychiatrists and psychiatric nurse practitioners, and is a medical professional available on site 24/7?
  • There should be a high staff to patient ratio, and a physically comfortable environment with lots of emotional support.
  • Do the staff seem mature to you?  Do they support each other, are they a team?  There is often heavy staff turnover at residential treatment centers because the work is emotionally draining, so staff cohesion is as important as the qualities of each individual.
  • Safety is paramount.  Staff must be able to safely manage the things that can go wrong with troubled kids.  They should be trained in NCI (Nonviolent Crisis Intervention), “training that focuses on prevention and offers proven strategies for safely defusing anxious, hostile, or violent behavior at the earliest possible stage.”

What to ask about programs:

  • Does the program specifically identify parent/family involvement as part of treatment?  Does it emphasize parent partnership with staff?  Ask.  Whether you live close or far from the center, even out-of-state, you should be regularly included in conversations with staff about your child’s treatment.  You should also be included in a therapy session with your child periodically; some facilities can connect with you over Skype.  Your child’s success in psychiatric care depends on their family’s direct involvement.
  • The program should coach you in specific parenting approaches that work for child’s behavioral needs.  While your child is learning new things and working on their own changes, you must also.
  • You should be informed why your child is getting the treatment or behavioral modifications he/she is receiving.

Body health is mind health, and vice versa.

  • residential programsMental health treatment will include medication and therapy, but must also include positive activities and an educational program.  The whole body needs care:  exercise, social activities, therapeutic activities (art, music, gardening), healthy food, restful sleep, etc.

Is your child emotionally safe as well as physically safe?

  • You should be able to visit the unit or cottage where your child will live, see their bedroom, and see how the other children interact with staff and how staff interact with each other.

What to ask about the business itself:

  • Can you take a tour ahead of time?  Can your child or teen visit too if appropriate?
  • Are emergency services nearby (hospital, law enforcement) that can arrive quickly?
  • Does the facility have a business license in their state?  Do they have grievance procedures?  Is the center accredited as a treatment facility, and by whom?  In the U.S., the main accreditation authority is called JCAHO (Joint Commission on Accreditation of Healthcare Organizations).

Psychiatric residential treatment works miracles, but it doesn’t work for all children.  Some need to go into treatment more than once to benefit. Some fall apart a few weeks or months after discharge.  These are common.  What’s important is that you and your child are taught skills for managing his or her unique symptoms, communicating well, and committing to staying well together.

Good luck.

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How to help your child cope with anxiety

How to help your child cope with anxiety
7 votes

anxiety2We all get anxious, but it becomes a “disorder” when it prevents a person from normal functioning. Anxiety and panic are very real, whether triggered by life in general or certain things such as phobias. Take it serious–it’s not something an extremely anxious child can “get over”.  Willpower alone does not work.

Anxiety disorders are also one of the most common psychiatric conditions in children and adolescents, but often go undetected and untreated. Early, effective treatment can reduce the negative impacts on academic and social functioning.

Excessive worry or anxiety about multiple issues, which lingers six months or more, can indicate an anxiety disorder. 

anxiety3Anxiety is often expressed in physical symptoms:

  • Anxious mood: excessive worry, anticipating the worst
  • Tension: startles or cries easily, restlessness, trembling
  • Phobias: fear of the dark, fear of strangers, fear of being alone, fear of animals, etc.
  • Insomnia: difficulty falling asleep or staying asleep, nightmares
  • Intellectual difficulties: poor concentration, memory impairment
  • Depression: decreased interest in activities, inability to feel happy
  • Somatic complaints (muscular): muscle aches or pains, teeth grinding
  • Somatic complaints (sensory): ringing in the ears, blurred vision
  • Cardiovascular symptoms: tachycardia, palpitations, chest pain, feeling faint
  • Respiratory symptoms: chest pressure, choking sensation, shortness of breath
  • Gastrointestinal symptoms: difficulty swallowing, nausea or vomiting, constipation, weight loss, abdominal fullness
  • Genitourinary symptoms: frequent or urgent urination, painful menstruation
  • Autonomic symptoms: dry mouth, flushing, pallor, sweating
  • Physical behavior: fidgeting, tremors, pacing
  • Other: risk of abusing alcohol in adolescence, cutting and other self-injury (not suicidal)

Cutting

Physical pain reduces psychological pain by shocking a person’s attention into the here-and-now.  Like a glass of water thrown into someone’s face when they are upset, the shock overrides inner turmoil, and releases adrenalin and endorphins.  It’s stimulating, even energizing.  According to statistics from research, cutting becomes addictive after about 14 episodes.

anxiety6True story: Laurel, age 14, cut herself regularly on her fingers, preferring to cut under her fingernails.  She hid the cuts and scabs with nail polish.  Her father eventually learned about this and asked her why: “I feel more calm because the sting feels good and distracts me.” A therapist recommended that Laurel draw “cuts” on herself with a red pen instead of a knife, and also wear a rubber band on her wrist or fingers and snap it when she wanted to feel a sting.

It is common for cutters to hide their scars or scabs under clothing if they think you will try to stop them, or they will cut in a place you won’t see unless they are unclothed.  They may also make an excuse about an injury if you do see visible cuts.  You can look for unexplained blood on clothing.  Don’t be afraid to ask if they are cutting; many young people have freely ‘confessed’ when asked.

Treatment for anxiety

anxiety5anxiety4A child or teen will often be diagnosed with more than one type of anxiety disorder, in addition to a psychiatric disorder–30% of all anxiety cases include a diagnosis of depression and attention-deficit/hyperactivity disorder.

Cognitive behavioral therapy (CBT), in combination with antidepressant medications “have consistently shown efficacy for anxiety disorders in children and adolescents.” Many anti-anxiety medications on the market are addictive, so a doctor or psychiatrist will be very cautious about prescribing them except on an as-needed basis. Treatment must also include parent involvement, especially if the parents are also anxious. In the case of cutting, allow your child to cause themselves pain that is harmless, for example:  hold tightly onto ice as long as they can, smell vinegar, taste hot pepper.  These may sound strange, but they are effective techniques used in Dialectical Behavior Therapy (DBT) to help an anxious person tolerate stress.  You find out more about CBT and DBT here:  Therapy types explained – DBT, CBT, CPS, and others

How you can help

  • Validate or affirm your child’s feelings. If he or she is worried, fearful, upset, or distraught, don’t insist they should not have their feelings, regardless of the reason. You can let your child know that feelings are normal and it’s OK to have a little fear at times.
  • Reduce their dependence on you. Help them learn to cope by offering less reassurance, which can undermine their commitment and skills for coping. Messages that “everything will turn out OK” teaches them that you will help them through all fears, but they need to learn that they can get through fear on their own.
  • Avoid helping too much. If you try to protect your child from all harm, it prevents them from becoming independent and keeps them socially immature; traits they need to learn in their teens. Learning and maturing require that kids handle challenges on their own by confronting small anxiety hurdles along the way.
  • Model how to cope*. A parent’s anxiety greatly aggravates their child’s anxiety.  If you are anxious, tell your child how you plan to cope with it. For example, “Sometimes I feel nervous when I have to climb a ladder, but I just need to take a deep breath, be careful, and do it. If I get too nervous, I can always climb back down, and try it again later.”

* Charles H. Elliott, Ph.D. “Anxiety: Three Messages to Avoid Giving Kids”

anxiety1Escape plans

If your child is in a situation where they are experiencing severe distress, always have an escape plan or an “out” so your child can leave the situation as quickly as possible. Prepare yourself ahead of time so you won’t feel inconvenienced when it happens, and accept this as part of their treatment needs.

  • This reduces anticipatory anxiety when they are exposed to stress, and teaches them how they can manage themselves on their own. This is also a teachable moment when you reinforce self-calming skills.
  • This builds trust in you and a willingness to listen to your guidance. (When I did this consistently, my child grew more comfortable in similar stressful situations.)

Don’t forget to take care of YOU and your foundation

Keep your energy in balance so you can maintain your family's foundation.  Too much spent on your child affects everything else your family needs to survive.

Keep your energy in balance so you can maintain your family’s foundation. Too much spent on your child affects everything else your family needs to survive.

 

 

 

 

 

 

 

 

If you’ve found ways to reduce your child’s anxiety, share them in the Comments section for others to consider.

–Margaret

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Brace yourself for borderlines

Brace yourself for borderlines
16 votes

Are you ready to bang your head on a wall?  Do you want to abandon your child in the wilderness?  Are you praying for the day they turn 18, when you can change the locks on your doors?  Children with borderline personality disorder (BPD) bring out the worst in everyone around them.

A borderline child or teen is not a “drama junkie” on purpose.  There brain is primed to overreact.

Yes, BPD kids really believe that others are out to get them, and that all their problems are someone else’s fault.  They are appalled that others mistreat them horribly.  They are insulted and defensive when they detect criticism, even when there isn’t any.  They can never be pleased, and it’s always about them.  Most exasperating for you, they turn from monstrous, to sweet and charming, and back to monstrous in an instant.

“Does this explain why I can go from 0 to 60 in two seconds?”
–17-year-old girl when told she was diagnosed with borderline personality disorder

Especially confusing, a borderline teen can be very engaging and affectionate… sometimes at random, and sometimes when they want something.  They will also turn on the charm to embarrass you in front of others (such as in family therapy).  Since they seem so wonderful to other people, you are asked why you get upset at your clearly wonderful child.  People often recommend that you take care of your own issues instead.

Even though their manipulation and upheaval is relentless, strive for compassion.  Trust me, your borderline child will suffer more than you in every important aspect of life.  They make a mess of their relationships because of their anger, instability, substance abuse.  Their clingy behavior is annoying.  They drive away good friends, hate them for leaving, and then suffer from loneliness and depression.  They make a mess of their jobs, often fired or forced to resign, and bounce from one to another… and they don’t understand why it happens to them.

For goodness sakes, why?

When playing a game that requires teamwork, the brain of a normal person shows activity in the bilateral anterior insula.

 

The brain of a borderline person, when playing the teamwork game, showed no activity whatsoever.

A study published in 2008 in Science showed that brain activity in people with borderline personality disorder was abnormal—their brains lack activity in the ‘cooperation’ and ‘trust’ regions, called the bilateral anterior insula.  Borderline personality patients do not have an internal, natural sense of fairness and social norms, and little to no level of trust.

Statistics

One research study reported that borderline personality disorder occurs as often in men and women, and sufferers often also have other mental illnesses or substance abuse problems.  (In my personal observations over many years, teenagers with borderline personality disorder are often diagnosed with bipolar disorder.) Another study reported, “The disorder occurs in all races, is prevalent in females (female-to-male ratios as high as 4:1), and typically presents by late adolescence.”  It is estimated 1.4 percent of adults in the United States have this disorder.

In infants:  the children who were later diagnosed with borderline personality were more sensitive, had excessive separation anxiety and were moodier. They had social delays in preschool and many more interpersonal issues in grade school, such as few friends and more conflicts with peers and authorities.

In teenagers:  they are more promiscuous, aggressive and impulsive, and more likely to use drugs and alcohol. Cutting and suicide are more common.  “…research shows that, by their 20s, people with the disorder are almost five times more likely to be hospitalized for suicidal behavior compared to people with major depression.”

 

Evidence for hope

“Trying to Weather the Storm” (excerpt)
Shari Roan, September 07, 2009, Los Angeles Times

“Borderlines have the thinnest skin, the shortest fuses and take the hardest knocks.  In psychiatrists’ offices, they have long been viewed as among the most challenging patients to treat.

“But almost 20 years after the designation of borderline personality disorder, understanding and hope have surfaced for people with the condition and their families.  Advances have been made in recent years.  Researchers from McLean Hospital in Massachusetts studied 290 hospitalized patients with the condition over a 10 year period:  93 percent of patients achieved a remission of symptoms lasting at least two years, and 86 percent for at least four years. Published in The American Journal of Psychiatry, the research argues that once recovery has been attained, it appears to last.

“Having a relative with BPD can be hell,” says Perry D. Hoffman, president of the National Education Alliance for BPD http://www.borderlinepersonalitydisorder.com.  “But our message to families is to please stay the course with your (child) because it’s crucial to their well-being.”

Treatment

“What Therapy Is Recommended for Borderline Personality Disorder in Adolescents (13-17 years)?”(excerpt)
Mary E. Muscari, PhD, August 9, 2005, http://www.medscape.com/viewarticle/508832

Psychotherapy is the primary treatment of BPD, specifically long-term dialectical behavior therapy (DBT), which helps the person attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning.  DBT appears to be the most effective.  It focuses on coping skills, so patients learn to better control their emotions and behaviors. This may be complemented with medications that help with mood stability, impulsivity, psychotic-like symptoms, and self-destructive behavior.

There are several appropriate therapies in addition to DBT, and all share common elements:  1. The bond between the patient and therapist is strong.  2. Therapy focuses on the present rather than the past, on changing one’s behavior patterns now regardless of how patients feel about the past or if they see themselves as victims.

On DBT:  I recommend this straightforward self-help lesson to get started learning the concepts and skills:  http://www.dbtselfhelp.com/html/dbt_lessons.html.

When to hospitalize

  • In an emergency – when your child has serious suicidal thoughts or an attempt, and/or is in imminent danger to others.
  • In long-term residential care – when your child has persistent suicidal thoughts, is unable to participate in therapy, has a life-threatening mental disorder (e.g. bipolar), continued risk of violent behavior, and other severe symptoms that interfere with living.

Other treatment a borderline may need:

  • Treatment for substance abuse.
  • Therapy that focuses on violent and antisocial behaviors, which can include emotional abuse or physical abuse, baiting, bullying, and sexualized behaviors.
  • Therapy that focuses on trauma and post traumatic issues when an adolescent loses their sense of reality.
  • Reduce stressors in the young person’s environment.  Most adolescents with BPD are very sensitive to difficult circumstances, for examples: an emotionally stressful atmosphere at home; teasing in school; pressures to succeed or change; consistent rules; being around others who are doing better than them, etc.

What parents and caregivers can do

With a partner or spouse:  Maintain a united front.  Communicate continually to stay on the same page when managing your child and setting limits.  Have each other’s back even if you’re not in full agreement.  Always take disagreements out of earshot of your child.  Any disagreement they hear will be used against you.

Maintain family balance.

Keep your energy in balance so you can maintain your family's foundation.  Too much spent on your child affects everything else your family needs to survive.

Keep your energy in balance so you can maintain your family’s foundation. Too much spent on your child affects everything else your family needs to survive.

 

Keep things relaxed.  If you need to set boundaries and apply pressure, do it only to maintain  appropriate behaviors and reminders for self-calming.  Let other things go.

Use praise proactively.  Borderlines crave attention and praise.  When they deserve it, pour it on thick.  And pour it on thick every single time they demonstrate good behavior and positive intention.  One can’t go too far.  When an argument or fight comes up, search your memory banks for the most recent praiseworthy thing they did or said, and bring it up and again express your gratitude and admiration.  This does two things:  it reinforces the positive;  and it redirects and ends a negative situation.

Become skilled in DBT and help your child stay in the here and now.  Keep up the reminders that enable them to stay in the moment, to take those extra few seconds to think things through before reacting.

  • Did your friend really intend to upset you?  It sounds like they were talking about something else.
  • The delay wasn’t planned just to make you mad, perhaps you were just frustrated by being asked to wait, and it was no one’s fault.
  • The tear in your jacket isn’t a catastrophe.  It is easily fixed and I can show you how.

Prevent dangerous risk taking – Teens with borderline personality are exceptionally impulsive and prone to risky behavior.  Consequently, parents should consider:

  • Tightly limiting cell phone use, email, texting, and access to social networking sites
  • Using technology to track their communications (this is legal), or disabling access during certain time periods
  • Reducing the amount of money and free time available
  • Searching their room (this is also legal)

A couple I know fully informed their borderline teen that all internet activity would be tracked, as well as cell phone calls.  The father also installed cameras in the home, at the front and back doors, in plain sight.  Nevertheless, his son continued with bullying and hurtful behavior towards siblings right in front of those cameras, and he would get caught and pay consequences repeatedly.  His persistence in the face of obvious monitoring became a great source of private amusement for his parents–humor really does provide relief.
–Margaret

Be patient – You are unlikely to receive the child’s respect, love, or thanks in the short-term.  It may take years.  But be reassured that your child will thank you for your firm guidance and limits once he or she matures to adulthood.

Other characteristics of BPD

Signs and symptoms of BPD may include significant fear of real or imagined abandonment; intense and unstable relationships that vacillate between extreme idealization and devaluation; markedly and persistently unstable self-image; significant and potentially self-damaging impulsivity (spending, sex, binge eating, gambling, substance abuse, and reckless driving); repeated suicidal behavior, gestures, or threats; self-mutilation (carving, burning, cutting, branding, picking and pulling at skin and hair, biting, and excessive tattooing and body piercing); persistent feelings of emptiness; inappropriate anger or trouble controlling anger; and temporary, stress-related severe dissociative symptoms or paranoid ideation.

  • Chronic depression: Depression results from ongoing feelings of abandonment.
  • Inability to be alone: Chronic fear of abandonment also leads to these adolescents having little tolerance for being alone. This results in a constant search for companionship, no matter how unsatisfying.
  • Clinging and distancing: Relationships tend to be disruptive due to the adolescents’ alternating clinging and distancing behaviors. When clinging, they may exhibit dependent, helpless, childlike behaviors. They over idealize he person they want to spend all their time with, constantly seeking that person out for reassurance. When they cannot be with their chosen person, they exhibit acting-out behaviors, such as temper tantrums and self-mutilation. Distancing is characterized by anger, hostility, and devaluation, usually arising from discomfort with closeness.
  • Splitting: Splitting arises from the adolescents’ inability to achieve object constancy and is the primary defense mechanism in BPD. They view all people, including themselves, as either all good or all bad.
  • Manipulation: Separation fears are so intense that these adolescents become masters of manipulation. They will do just about anything to achieve relief from their separation anxiety, but their most common ploy is to play one individual against another.
  • Self-destructive behaviors: The behaviors are typically manipulative gestures, but some acts can prove fatal. Suicide attempts are not uncommon yet usually happen in relatively safe scenarios, such as swallowing pills at home while reporting the deed to another person on the telephone.
  • Impulsivity: Poor impulse control can lead to substance abuse, binge eating, reckless driving, sexual promiscuity, excessive spending, or gambling. These behaviors can occur in response to real or perceived abandonment.

 

Drawn from:
Risk taking adolescents: When and how to intervene (excerpt)
David Husted, MD, Nathan Shapira, MD, PhD , 2004
University of Florida College of Medicine, Gainesville

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How am I doing?  Please rate this article at the top, thanks!

–Margaret

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Filed under bipolar disorder, borderline personality disorder, Bullying, cutting, suicide, teenagers