Girls surprised during a movieFilms that depict mental health issues often do well at the box office. Some of them, such as One Flew Over the Cuckoo’s Nest, go on to win Oscars and become classics. Many people have an interest in films about mental health because they shed light on conditions that many may not understand. Across genres, audiences have been captivated by films with underlying mental health themes ranging from schizophrenia to codependency to psychosis.

Although they may be earnest in their depiction, it is important to note that not every movie that addresses mental health is accurate when it comes to the portrayal of mental health characteristics, and mental health symptoms can vary from person to person. If a movie with a mental health theme piques your curiosity, you can visit GoodTherapy.org’s PsychPedia to learn more about specific conditions.

Here are some examples of mainstream fictional films depicting a range of mental health conditions you can watch for information, entertainment, and intrigue.

1. Shutter Island (2010) (Posttraumatic Stress, Psychosis)

If intense psychological thrillers are what you seek, Shutter Island is a movie you may want to watch. It will leave you wondering if Teddy Daniels—the main character played by Leonardo DiCaprio—is really experiencing delusions.

U.S. Marshal Teddy Daniels and his partner head to a psychiatric hospital located on an island to determine what happened to a missing patient. Not long after showing up, bizarre occurrences happen and it would seem that the supposed U.S. marshal turns out to be Andrew Laeddis—the facility’s most dangerous patient. His therapist, who is well aware of Teddy’s delusions, prompts him to act out his delusion, hoping that the delusion will break so he can face reality.

But a painful reality may be easier to run from than face and accept. It would seem as if Teddy agrees and at the end of the movie he asks an interesting question: “This place makes me wonder which would be worse—to live as a monster, or to die as a good man?”

According to many who interpret this question, Teddy is aware that if he accepts his guilt of the horrific tragedy that happened to his family, he will be forced to live with the pain. On the other hand, if he continues to live in his delusion, he can live and eventually die unaware of the crimes he committed.

2. The Soloist (2009) (Schizophrenia)

The Soloist is a movie that looks at the life of a person experiencing schizophrenia. The movie is based on the true story of Nathanial Ayers, a promising student at the prestigious Julliard School who experiences a mental breakdown during his third year at Julliard. Perhaps the pressure was too much, or maybe he had been experiencing mild symptoms until they became severe enough to cause a disruption in his life.

For various reasons, including his refusal to take medication for schizophrenia, Nathanial becomes homeless. Steve Lopez, a journalist, meets Nathanial in Los Angeles and the two become friends. Lopez, upon discovering that Nathanial can play the cello brilliantly, sets out on a mission to help him with his mental health.

The Soloist demonstrates how untreated mental health challenges can contribute to a person slipping through society’s cracks. It also depicts how reaching out can have a profound impact on the life of someone experiencing a mental health issue.

3. Prozac Nation (2001) (Depression, Substance Abuse)

[fat_widget_right] Sex, drugs, and rock and roll may have been an “escape” back in the ‘60s and ‘70s, but the reality is that many people seeking these escapes may be dealing with underlying issues. Prozac Nation furnishes watchers with a deep look at the world of those experiencing depression and substance abuse.

The movie follows Lizzie (portrayed by Christina Ricci) as she tries to overcome severe depression without medication. She instead tries to treat herself using drugs, sex, self-mutilation, and escapism. She balks at reality and tries to commit suicide, severs relationships with her family, treats others around her in an abhorrent way, and seems to have no hope until she is put on a new medication called Prozac. This movie sheds some light on how antidepressants can help some people dampen the symptoms of severe depression and seek treatment.

4. The Hours (2002) (Depression)

This movie about mental health examines the lives of three women who are coping with depression. The story depicts three generations of women throughout various stages in their lives.

Depression impacts each of the protagonists in the film. Author Virginia Woolf is writing the story of Mrs Dalloway in 1923, while grappling with depression, suicidal ideation, and her sexual orientation; a young mother in 1951 struggles with reservations about her role in her family, her sexuality, and suicidal ideation; and Clarissa Vaughan, a publisher, questions her role in the lives of her loved ones in 2001. This film illustrates the weight of depression and introduces the question, “Is it better to live life based upon doing what you want in order to be happy, or on others’ expectations?”

5. One Flew Over the Cuckoo’s Nest (1975) (Antisocial Personality)

One Flew Over the Cuckoo’s Nest is a classic film about mental health and psychiatry, based on the novel of the same name by Ken Kesey. Jack Nicholson plays R.P. McMurphy, who is in a mental institution after committing a crime.

The movie paints a picture of how in the not so distant past mental health institutions were sometimes operated inhumanely. Its scenes of electroshock therapy and lobotomies were once considered normal paths to recovery for many people experiencing mental concerns. The film emphasizes that people with mental health diagnoses are human and ought to be treated with dignity.

6. Ordinary People (1980) (Depression)

In this mental health film starring Donald Sutherland and Mary Tyler Moore, you meet a family coping with grief after the death of one of the sons. The living son cannot bear the loss and tries to commit suicide. The family begins treatment for him and an emotional journey for the whole family ensues.

This film explains how grief manifests in different ways. The boy is stigmatized at school, and family life is hectic and tense at times. Ordinary People gives viewers insight into how tragedy can cause disruptions in regard to both mental health and family dynamics.

7. Girl, Interrupted (1999) (Borderline Personality)

Girl, Interrupted, starring Winona Ryder, is set in 1967 and tells the story of Susanna, an 18-year-old woman who is experiencing feelings of depression and has many unanswered, self-reflective questions. After a suicide attempt, she is sent to a psychiatric institution to receive the help her parents feel she needs. Reluctantly, she goes and meets other women who have their own mental health issues they are living with. Once she is there for a period of time, she is given the diagnosis of borderline personality and struggles to accept it.

Learn More about Mental Health

These films and others give us glimpses into other people’s experiences, thoughts, and behaviors and invite us to expand our awareness when it come to mental health issues. If you wish to understand a mental health condition that you or a loved one are experiencing, you can always seek the help of a qualified therapist. Therapy can help you cope with unwanted symptoms and take steps toward creating a happier, healthier life. Mental health concerns can be detrimental to your well-being, but they do not define you as a person and there is help available in your community.

Portrait of beautiful 35 year old woman“If I am killed, I can die but once; but to live in constant dread of it is to die over and over again.” —Abraham Lincoln

“Something did happen to me somewhere that robbed me of confidence and courage and left me with a fear of discovery and change and a positive dread of everything unknown that may occur.” ―Joseph Heller

I recently came across the above quote by Joseph Heller and it hit me right to my very depths. I remember as a child actively learning to—in essence—feel constant dread, as I taught myself to avoid disappointment and failure by always anticipating the worst. That way, when it came to be, I wouldn’t be devastated—just fatalistically accepting. It gave me a sense of control when I felt none. In so doing, I—like Joseph Heller—set into motion a lifelong habit of dreading just about everything. In fact, it has so pervaded my thinking that I have often observed myself dreading a fun or enjoyable event, just because it is my habit to do so.

The above description might not be exactly true for you (I hope it is not!), but it is a common state for many people in our culture. Most of us were not taught to deal with adversity in a healthy way, so we learned or taught ourselves how to avoid pain. As for me, as I’ve gotten older, gone through several rounds of psychotherapy, and explored many different spiritual traditions for help with dread, I have learned to work with the feelings. I’ve also helped many people deal with these same kinds of feelings. So what has worked?

I think the great Sufi poet Rumi expressed it best in his poem, The Guest House (excerpt):

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The dark thought, the shame, the malice, meet them at the door laughing, and invite them in.

Be grateful for whoever comes, because each has been sent as a guide from beyond.

Most of us spend a lot of our time fighting this sense of dread, feeling powerless to combat it and completely at its whim. We push it away, only to find it resurfaces at just the wrong time! Once you recognize this cycle, you can simply accept this dread that is so often present instead of fighting it off. When it arrives, allow it to be there without beating yourself up. Take some deep, yogic breaths to quiet your mind a bit, and then ask yourself some questions:

The more I have practiced this, the more I have been able to “work with” the dread and not allow it to disable me from living fully. There are days when I have to go through the above steps many times, and yet others where I am fully engaged moment-to-moment and don’t have the “time” to dread.

Next time you can’t get out of dread, try teaching yourself that you can: once you loosen your attachment to those feelings, they have way less power over you than you might think.

Man consoles woman looking downEditor’s note: Susan Heitler, PhD is a clinical psychologist specializing in healthy conflict resolution and the author of The Power of Two, a workbook for couples. Her continuing education presentation for GoodTherapy.org, titled Narcissistic Habits: Couples Therapy Treatment Techniques, is scheduled for 9 a.m. Pacific Time on September 19, 2014. The event is available at no additional cost to GoodTherapy.org members and is good for two CE credits. For details, or to register, please click here.

Codependency as a personality diagnosis is a label with significant limitations. Having emerged initially from the world of alcohol and drug treatment, codependence neatly describes the husband who makes excuses to his wife’s friends to cover for his wife’s evening drinking binges. In that context, the husband is acting as a codependent in the sense of fostering his wife’s alcohol dependency. For use beyond the arena of alcohol and drug dependency treatment, however, the term needs an upgrade.

For instance, Jack who is married to a quick-to-anger woman with narcissism, strengthens his wife Julie’s narcissism when he self-smothers his inner voices lest he say something that might arouse Julie’s ire. Similarly, a corporate assistant, Brenda, fosters her boss Peter’s self-defeating workaholic tendencies when she consents to work late hours to help him tackle too many tasks. While Julie’s narcissism and Peter’s work excesses both create problems, the narcissism and workaholic patterns are not “dependencies” in the sense of a drug dependence. So describing Jack or Brenda’s enabling behaviors as codependent stretches the term excessively.

The term enabler—commonly used as a synonym for codependent—may be a more fitting alternative. Jack functions as an enabler when he smothers his own preferences, fostering his wife Julie’s narcissism. Brenda functions as an enabler when she too often works late to help her boss Peter complete the excessive number of work projects he has taken on.

The True Nature of Codependency

Although codependence may be better labeled as enabling, the phenomenon merits further clarification. To this end, I have coined four additional terms that clarify the internal experience of “codependent” enabling: excessive altruism, appendagitis, wishful thinking, and misplaced locus of focus.

While I speak these terms with my tongue somewhat in my cheek, diagnostic language is clinically useful to the extent that it guides therapeutic interventions. These terms, for me, pass that test.

Susan Heitler
Susan Heitler, PhD

What’s more, the new terminology brings an added bonus to treatment. Clients almost always chuckle when I tell them with exaggerated seriousness, “I’m afraid that you have a quite serious case of wishful thinking” (or either of the other three terms). Humor relaxes them so they are more open to accepting feedback on these self-defeating phenomena.

What Is Excessive Altruism?

Giving feels good. By contrast an excessive inclination to help others through giving—that is, giving more time, money, energy, or affection than feels do-able—incurs a sense of burden.

In healthy partnerships altruism is a two-way street. Hopefully each partner gives and receives ample affection and appreciation, the ultimate contributions of value in relationships. The contributions needn’t be identical: One partner may cook, the other may wash dishes and take out garbage, so long as the contributions are subjectively felt to be of similar value.

When the overall traffic of giving and receiving feels approximately equal from both sides, goodwill prevails. Excessive altruism and/or selfishness, by contrast, unbalance the giving and getting, inviting resentment.

What Is Appendagitis?

Appendagitis characterizes an attachment in which one person serves as another person’s additional appendage. This psychological diagnosis is not to be confused with Epiploic appendagitis, a self-limiting inflammatory process of the epiploic appendices which are small, fat-filled projections along the surface of the colon and rectum.

Psychological appendagitis occurs when individuals shed their own preferences, life goals, and voice, and instead devote all their energies to another, such as a spouse, boss, or friend with needy or narcissistic tendencies. This shift usually is motivated out of a mixture of love and fear that without this shift they may incur the other’s anger and/or lose the relationship.

What Is Wishful Thinking?

Wishful thinking is the cognitive habit of believing that others will change when there is no realistic basis for this hope.

Brenda wishes her boss would become more appreciative of her efforts. She devotes ever-increasing efforts to please him in misplaced hope that someday he will change into a person who expresses gratitude and praise.

[fat_widget_right]Jack likewise wishes that his wife Julie would become less self-centered, entitled to special treatment, and quick to anger, but when Jack tries to discuss these concerns with her, Julie immediately erupts in anger, turning on him with blame that the problems are in fact his fault. Julie’s blaming responses indicate that the likelihood of her making changes is very low.

What Is Misplaced Locus of Focus?

A locus is defined as a place—a center of activity—where something occurs. Misplaced locus of focus means that someone’s attention is riveted to reading another’s thoughts, feelings, and facial expressions, periferalizing their awareness of their own thoughts and feelings, and assuming or guessing what the other person is thinking instead of asking.

Brenda, for example, stayed late at work three nights in a row. When her boss, Peter, was surprised to find her still in the office, she explained, “I thought it would make you less stressed, more relaxed, if I could get this report out before the weekend. I’m here working late because I thought it would make you happy.”

“Actually,” Peter responded, “I want to wait a month before sending the report out. I have more information coming in over the next few weeks that I’ll want to include in it.”

Brenda was disappointed to discover that she not only failed to anticipate Peter’s needs, but also neglected the needs of herself and her friends with whom she had cancelled plans in order to fulfill her boss’s needs.      

When Is Helping Others a Good Thing? When Is It Excessive?

Codependent-like behaviors have their healthy variants. Infants and young children for instance depend upon the consistent attentions of parents to stay alive. Parents’ responsivity, attunement, and nurturance contribute positively to the survival and thriving of young children.

At the same time, even parents can go overboard on attending to their young, allowing attunement and nurturing to slip inadvertently into appendagitis. Jack, the devoted husband and dad of four young children, often gets overwhelmed at breakfast time when he asks his wife and each of their children, “What would each of you like for breakfast today?” Bacon for this one, scrambled eggs for that, a fried egg for another, sunny side up with pancakes for the fourth, and French toast for the next. What’s wrong with this picture?

In other large families, parents put cereal and bowls on an accessible shelf where even the younger children can reach the boxes and pour their own, adding fruit, nuts, and milk. Maybe Mom or Dad cooks toast and eggs, and sometimes even pancakes, but only one kind of food is on the menu for everyone.

By catering to each individual’s daily preference, Jack’s excessive altruism is training his children in unrealistic expectations. He is fostering dependence and narcissism instead of training his children to become increasingly independent, to adapt to living as part of a group, and to be considerate of their dad’s time and energies.

Behaviors like altruism become problematic when people dedicate their energies to another person (1) to their own detriment, (2) to the detriment of the receiver and (3) when the other does not want the help.

For instance, Brenda suffers unhealthy appendagitis to the extent to which she allows her contribution of extra work hours to be exploited. Does she get paid? Does she really want to devote these additional hours to work? Also, while she believes she is helping her boss Peter, Brenda may actually be harming him by encouraging his tendencies to take on more and more until he is ready to collapse from stress and fatigue.

What Causes Excessive Altruism, Appendagitis, Wishful Thinking, and Misplaced Locus of Focus?

The all-about you attachment stance of people with the four enabling tendencies described above inadvertently attracts individuals with narcissism who love being the focus of someone’s attention and adulation. A hallmark of narcissism attachment patterns is an all-about-me stance that allows the coupling of enabling and narcissistic habits to seem, initially at least, to dovetail beautifully.

In enabler-narcissist partnerships, all-about-you habits may then be sustained because they seem to attenuate the narcissistic partner’s quickness to criticism, controlling behaviors, and anger. For someone trying to live in relative harmony with a narcissistic partner, these seemingly self-defeating habits may in fact help.

Family of origin can also play a role in creating a template for enabler interactions. Most often, individuals who develop excessive altruism, appendagitis, wishful thinking, and misplaced locus of focus are repeating patterns they observed in their parents’ marriage relationship. A child learns to speak French by hearing French spoken at home. We learn interaction and survival habits the same way, by hearing and observing our parents.

Children also may become highly skilled at enabling habits in order to cope with a narcissistic parent. Parents with narcissism insist that their children ignore their own preferences and become instead what the parent wants them to do and be. The development of enabling habits, like appendagitis, offers children of narcissists less animosity and more positive attention than if they were to interact with the parent in a more emotionally healthy manner. Children learn to do whatever contortions they must to retain the necessary positive attentions of their caretakers. Survival of the bond with the attachment figure is a first priority.

Treatment Implications for Each of These Terms

Excessive altruism, appendagitis, wishful thinking, and misplaced locus of focus each exacerbate the other, creating a vicious downward cycle of circular causation with ever-increasing anger, depression, and relationship dissatisfaction. What can reverse this cycle so that the spin switches upward toward ever-more positive feelings?

Excessive altruism leads to feeling over-burdened and resentful toward those on the receiving end of the giving. Folks with excessive altruism therefore need to learn to balance their giving to others with self-care.

Similarly, people with appendagitis need to refocus their attention on themselves. They need to turn up the volume on their own thoughts and preferences so they can hear their inner drummer. They then need to learn to speak up tactfully and still effectively about what they feel and want. Lastly, they need to learn win-win ways of making decisions so that the partner with narcissisism is less likely to feel disempowered, wrong, or like a loser.

Wishful thinking creates a faulty personal guidance system. Therapy that clarifies the realities regarding the other person’s repeated motivations and behavior patterns enables the development of better life decisions. The narcissistic partner may someday change, but often only after the wishful thinking partner first has begun making decisions based on reality.

Misplaced locus of focus can be reversed with practice drills on utilization of new sentence starters. For example, each time clients use the sentence-starters such as “I feel … ,” “My concern is … ,” and “I would like to … ,” their locus of focus must switch to their own inner feelings and thoughts in order to complete the sentence.

A change of habits seldom comes with a “Get Out of Jail Free” card. As Jack ceases to foster Julie’s narcissism, it therefore is vitally important that Julie be included in the treatment process, preferably in a couples therapy treatment format, so that the two spouses can change and grow simultaneously. If so, Julie and Jack are likely to end up feeling increasingly loving toward each other and happier within themselves. If not, they are likely to end up divorced.

As to Brenda, if she embarks on therapeutic change Brenda may lose interest in continuing to work for Peter. On the other hand, Brenda’s growth could free Peter as well, so that he may enjoy a fuller life less clogged by work.

Words have power. Naming a phenomenon helps to clarify what a phenomenon is and does, and how to attenuate its negative impacts. Each of the playful terms introduced in this article can help therapists to guide their codependent/enabler clients to awareness and correction of the technical mistakes they have been making, leading them toward the more positive emotions and fulfilling relationships that they have come to therapy to discover.

Person leaning over attaches helmet securely to child wrapped in bubble wrapA child changes everything. As a parent, you start seeing things from a completely different perspective. Whereas you would not have bothered before about cars driving too fast on a suburban street, now you find yourself yelling out, “Slow down, there’re kids in this neighborhood!”

Being a parent brings on a new sense of responsibility. At least one study shows that dads start spending more time at the office after having a child, working harder, hoping for a promotion. Another group of studies show that stress increases significantly for new parents, and some even suggest that, because of the added stress, parents are not much happier than their childless counterparts.

Ah, responsibility. You hold that little bundle of sleepless joy in your arms, and tell them, “I will never let anything happen to you. I promise. I will dedicate my life to you, and you will be the happiest person to ever walk this earth.” However, raising the smartest, happiest, and most amazing human being is a lot of work. Just keeping a child alive is huge responsibility!

The constant pressure can lead you to over-parent your child. Your desire to shield and protect them at all times allows the child little room for making mistakes.

Children, and people in general, learn best from experience. If a parent constantly guides a child to assure the child’s success, then the child may not know what to do when left to their own devices.

A common sign of over-parenting is when parents express worries in the form of instructions. For example: “Don’t fall!” How does that statement reduce the child’s chances of falling? Another one: “Be good.” Instead of helping your child succeed, these vague statements communicate mistrust in the child’s abilities.

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Another sign of over-parenting is when a parent rushes in to fix a child’s problems to avoid the child becoming upset. When a child loses a toy, they get a new one. When a pet dies, and parents are overwhelmed with their child’s feelings of grief, they might rush to the pet store for a new animal to replace their child’s best friend.

So, what’s a loving parent to do? What if the parent has a superpower to foresee danger. Should the parent not give warnings? Step in to save the day?

Here are some suggestions on how to step back so your child can step up:

Above all, remember that your child will benefit from learning to figure things out. A child will be more careful holding an ice cream cone after dropping it once. And if it’s their emotional well-being you are looking out for, keep in mind that the way in which your child is able to overcome difficulties is what will make them feel successful and empowered. Our children are often stronger, wiser, and more responsible than we think.

Woman covering her earsCan you understand how a driver might want to ram another car off the roadway in a fit of rage just because he or she was cut off at a light? Maybe that’s even you? If so, you are not alone—more than 16 million people struggle with anger while driving.

Of course, anger rears its ugly head in many different forms—so-called “road rage” is just one. No one is immune to feelings of rage, frustration, anger, or irritation at one time or another. I have been coaching anger-management skills in my private practice over many years in addition to teaching 52-week, mandated domestic violence classes to male offenders and working with high school gang members. I am passionate about teaching pissed-off, posturing individuals why anger is one of the most important emotions they have and how it can be used to serve them.

When I am coaching anger-management skills, I am quick to start the conversation by emphasizing that the goal of what I am teaching is not to help a person never to experience anger. Anger will never go completely away for anyone. A primary goal of anger management is to help the person learn how to control his or her anger, learn from it, and use it appropriately in a given situation. (I am not suggesting that violent acts against others are ever appropriate; I am focusing on the underlying feelings of anger and what it is trying to tell us about ourselves.)

In my work with regular folks, gang members, and domestic violence offenders, I have found many ways that anger serves us, but these five seem to be the most prevalent:

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  1. Anger sets boundaries around us when we feel threatened. When something feels intuitively wrong to us, as when we are being mistreated, we tend to feel anger. This is an internal sign to us that we need to remove ourselves from a situation that is not treating us well.
  2. Anger covers up an emotion that we are not comfortable feeling. Many times when a person is angry, he or she actually has an underlying feeling going on, such as guilt, sadness, vulnerability, or fear. These feelings are so uncomfortable that the person would rather get angry than feel the underlying emotion. When you feel anger, one of the first questions to ask yourself is: what emotion am I trying to avoid?
  3. Anger acts like a suit of armor. Anger keeps others away from us and gives us space. Many times this can be an effective defense mechanism if we need space or want to work something out. Teenagers use anger in this way a lot to give themselves space away from a situation that they are not able to handle.
  4. Anger can prepare you for battle. As anyone who has ever gotten into a physical altercation with someone threatening can tell you, you need to energize yourself and pump up your adrenaline in a way that will be accessible to you in an emergency. Anger can harness your power in order to physically protect you if you are being hurt.
  5. Anger can point you to unresolved internal issues. If you find yourself having feelings of anger when you think of someone in your life, an issue from your childhood, or a future event that you are dreading, you more than likely have something unresolved going on. Maybe your friend asked you to help host a neighborhood barbecue and you have trouble saying no, when you really don’t want to help. You feel resentment and anger toward your friend, when in fact you are the one who has trouble setting boundaries and saying no. Or maybe you hold anger from a breakup that has left you lacking in trust of the opposite sex, and every time you think of your ex you get angry and bitter. You can use this feeling of anger to realize that you may need to get some closure or process this termination of your relationship so you can learn how to let it go and move on.

In learning how to become a better listener to your feelings of anger as they arise, you can begin to learn things about yourself that you may not have known. You will never be free of anger popping up in your life, and that doesn’t have to be a bad thing. As the above list points out, anger is an incredibly valuable guide to help you gain insight into your true self.

GoodTherapy | Your Move, Parent: What to Do When Your Teen Is CuttingYou look over at your lovely daughter and think to yourself how time flies. Gazing at her with love, you notice red marks and lines on her youthful arms. Immediate panic sets in; you reach over with shock and say, “What is this?!” Your parental urgency sounds like terror, and your daughter pulls away quickly and rebuffs your concern. She retreats to her room, and you are left wondering where you went wrong and concerned that she’s in danger.

As much as it’s an unwanted membership, you’ve just joined with other parents who have children who cut. You may not even know that’s what you’ve exposed, but most likely it is. If your child has been acting more irritable, overwhelmed, and on edge, be aware of the signs of potential self-harm. Generally, the signs distinct to a person who cuts include:

The biggest question becomes, then, what do we do as parents? Here are some suggestions to help you parent through this challenging time:

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  1. Don’t freak out. This is the hardest part for parents, but a necessary one with teens. If you freak out, they freak out. They are just as afraid of their behavior as you are, and if they see you unable to control yourself and handle it, how is there hope for them to cope? Instead, breathe, think it through, and speak calmly.
  2. Check your anxiety. How do you handle your anxiety? Do they see you cope in healthy ways or do you create maladaptive behaviors as well? Are you stressed all the time, yell at everyone, and otherwise handle life poorly? Remember, they are watching you.
  3. Ask them if they want to talk about it, and create opportunities for them to talk. Forcing teens to talk is a recipe for disaster. Instead, be available and let them know repeatedly that you are there to listen if they want to talk. They will appreciate that they can choose to talk or not, and that you are accessible. Create time and opportunities to engage with them.
  4. Don’t embarrass them by telling all your friends. As much as being secretive is damaging, so is telling everyone you know because YOU can’t handle it. This is the time to put your teen’s feelings first and care for them without alerting the media.
  5. Know your limits. If this is too much to handle, seek help for your teen. Self-harm is relatively newly acknowledged and understood as a coping mechanism. A mental health provider can provide guidance and teach appropriate techniques to help your teen handle life.
  6. Don’t tell them to stop cutting. Telling your teen to “knock it off” or “don’t do it again” is simply asking for rebellion. Although that’s how we feel and what we want to say, it’s best to understand the behavior fully before seeking demands.
  7. Create a plan. This is a great time to create a plan for healthy coping mechanisms. Brainstorm with your teen alternative solutions during stressful times. Maybe they can go for a walk, call a friend, bake a cake, draw, listen to music, watch a movie, or journal. This can be a fun activity to do together—use your creativity!
  8. Spend one-on-one time with your teen. Kids spell love: T-I-M-E. Make time.

Discovering that your teen cuts may lead to panic and unease. How you handle yourself during this scary time can create a path to peace or leave a destructive wake. Checking yourself and your own anxiety can be a powerful tool to teaching your teen how to do it, too.

office environment with four coworkers (blurred)Most of us experience work stress, but can too many responsibilities, unrealistic expectations, and personality conflicts at work lead to an experience of trauma victimization over time?

In my years of private psychotherapy practice, I’ve seen several cases where individuals experience signs similar to posttraumatic stress as a result of work problems. In the beginning, I found this slightly odd. I wondered: could negative work experiences really lead to reactions similar to trauma experiences, like war or sexual assault? Lately, in conversations with colleagues, I’ve discovered this is fairly common, particularly in certain professions.

How Your Work Environment Can Leave You Feeling Victimized

I recently interviewed Arkansas professional counselor Rev. Rebecca Spooner, an ordained minister who left ministry to become a therapist. She specializes in counseling pastors and their families, and said that feeling victimized and traumatized by their work environment is relatively common among members of the clergy. Rev. Spooner explained that the demands and expectations of modern ministry set pastors up for personal failure and emotional trauma.

“The paradigms in ministry are flawed,” Spooner said. “A hundred years ago, pastors had four jobs: marry, bury, baptize, and preach on Sunday. Today, ministers are expected to be marriage therapists and grief counselors, organizational leaders, facilities and staff managers, marketing coordinators, community relations specialists, bloggers, motivational speakers, spiritual teachers, salespeople (increasing membership and giving), budget managers, visit the sick, be a friend, and serve on regional committees! It’s completely unrealistic. It sets everyone up for disappointment.”

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These experiences are similar to what’s happening in private companies in recent times, particularly since the economic crash of 2008. Companies have laid off people and expect those who remain to do more work for less pay. New performance measures are adding pressure, and employees are micromanaged. Among the EAP (Employee Assistance Program) referrals I see in my office, stress related to new and unrealistic work performance expectations ranks at the top of the list.

The people who see me for help with work-related stress have complaints that are similar to what Rev. Spooner sees among clergy: insomnia, irritability, mood swings, anger, feelings of disappointment and disillusionment about their career and employer, confusion about why they are unable to meet the demands placed on them, hopelessness, anxiety and fear, fatigue, muscle tension, family problems, feelings of isolation, ineffective coping, and substance abuse. It’s a long list! Work stress is a big problem in America.

Many of us are familiar with trauma reactions after major catastrophes, but few of us realize that a work environment characterized by unrealistic demands, personality conflicts, and limited free time for leisure can, over time, create an experience of victimization.

3 Ways Cognitive Behavioral Therapy Can Help

Cognitive behavioral therapy (CBT) helps individuals shift from perceiving themselves as having little control over their circumstances to becoming empowered to either change outside pressures or learn to cope with and relate to them differently. With practice, CBT techniques can help reduce stress and anxiety, improve mood, and increase confidence.

CBT treatment has helped ministers reduce the experience of stress and trauma caused by the challenges of their profession. These same techniques can also help most people heal from various traumatic and emotionally difficult situations. CBT reduces distress and helps to restore emotional balance. Here are three techniques from cognitive behavioral therapy to use in your own life.

  1. Learn to identify the thoughts that increase your anxiety and your self-doubt. A large majority of individuals who come to see me for anxiety therapy are quite surprised when I mention that their thoughts are likely causing their anxiety. Most people believe anxiety is something that happens to them, something over which they have no control. But in fact, how we talk to ourselves about the situations we face has a great deal to do with how we feel. For example, if a minister tells herself that because her church is not growing she is not an effective leader and has failed God, she is likely to feel emotionally upset and believe that she is not capable of growing the church. By repeating self-defeating thoughts in her head, her self-esteem erodes. Eventually, she may just give up trying altogether and become depressed. This is the trick trauma plays on us: it tells us that something is wrong with us and that we are helpless, but most of the time our thoughts are not true.
  2. Dispute the thought. Once you’ve identified the anxiety-producing or self-defeating thought, it’s time to dispute it. Here’s an example: “If I don’t grow the church, I’ll get fired.” Let’s examine if that thought is true. In most denominations, firing a pastor takes effort. First, the leadership of the church has to vote that they have lost confidence in the pastor. Then, they have to bring the issue to a congregational vote. In many cases, a national mediator becomes involved to help resolve the conflict and improve the employee/employer relationship between the church and the pastor. So the thought, “If I don’t grow the church, I’ll get fired” is not exactly true. What’s much more likely to happen is that if the church is not growing and leaders are dissatisfied, a conversation will occur about why that’s happening. And hopefully, that conversation will lead to solutions. Notice your own thoughts and question them. Are they true? How do you know for sure? What are some alternative explanations that might be more true?
  3. Learn to relax. The third CBT technique that Rev. Spooner uses is relaxation training. When we learn to relax the tension in our muscles and reduce the speed of our thoughts, our brains function better. They see things more clearly. Gen. Colin Powell has a rule. He tells himself, “It ain’t as bad as you think. It will look better in the morning.” That’s partly because when our brains are rested, we see situations differently. Relaxation training can teach you to rest your brain. My personal hope is that one day, we will collectively learn to be realistic about our demands and expectations of people and be kinder to one another. Until then, if you find yourself feeling victimized, excessively pressured, or doubt your worth or abilities, try CBT. It really can help!

mother holding daughter and waving off fatherOver the past few years since starting my private practice, I have seen and worked with numerous families where a divorce was either in progress or had already occurred and child-custody disputes were in progress. Sometimes, one parent will alienate a child from the other parent out of anger, desire for revenge, jealousy, feelings of betrayal, rejection, etc. The child becomes enmeshed with the alienating parent and believes he or she must align with the alienating parent. The child may also actively participate in the process of alienating the other parent. This phenomenon is known as parental alienation syndrome (PAS).

When I observe families struggling with this type of dynamic, it brings to my awareness the victimizing nature of parental alienation syndrome for the child and the parent being alienated. The child wants to be loyal to both parents, and when he or she feels an “invisible loyalty” to one, it creates a high level of anxiety for him or her. This is a war the child cannot win.

Often, the parent affected by PAS will say negative things about the other parent to the child, with the objective of alienating the other parent from the child. The child can become virtually brainwashed into believing that the other parent deserves to be alienated, and may actively participate in denigrating the parent being alienated. The parent being alienated often feels protective, but is unable to stop the negative impact of PAS on the child and the relationship with the child. The biggest victim in this scenario is the child, as he or she will suffer the most from the fallout.

Parental alienation syndrome steals the bond and security that the child once experienced with the parent being alienated. In addition, PAS typically involves destructive behaviors such as manipulation, lying, and deprivation. Parental alienation syndrome robs a child of the ability to trust others as well as his or her own perceptions about life. In other words, he or she begins to distrust himself/herself as well as carry guilt. Parental alienation syndrome puts a child in a position of believing that the love and bond he or she has with a parent is contingent upon sacrificing the other parent, and they actively participate in protecting the parent responsible for alienating the other.

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If PAS is successful, the long-term emotional impact on a child may severely limit his or her ability to form healthy relationships and to develop emotional attachment to others. In addition, PAS may have a negative impact on a child’s self-esteem and confidence, which affects a child’s general attitude about life.

Parents must recognize that when they decide to divorce and children are involved, their relationship is not ending; it’s changing. Despite the charged emotions that often surface between parents who are divorcing, they must still collaborate about what is in the best interest of their child. The “tug of war” that PAS creates for a child with one or both parents should be avoided at all costs.

The following are some things parents can do to successfully challenge the alienating parent in the phenomenon of PAS:

checklist of things to doIn helping children, adolescents, and even adults with attention-deficit hyperactivity (ADHD), a checklist is a basic but extremely effective tool if used properly. Checklists are helpful in remembering to complete tasks, staying on track with budgeting time, and maintaining a record.

Here are a few common uses for checklists among those affected by ADHD:

Here are some suggestions on how to display a checklist:

Over time, individuals often learn to internalize the idea of a checklist and may be able to carry out routine tasks successfully without having to continue to rely on a physical checklist.

A sample checklist for a morning routine:

__ Brush teeth

__ Shower

__ Make bed

__ Get dressed

__ Eat breakfast

__ Pack backpack

One can include specific time-frame goals for tasks to be completed as well (i.e., “pack backpack – 7:45 a.m.”).

A sample checklist for homework assignments:

__ Math: worksheet (10 minutes)

__ English: chapters 4 and 5 (30 minutes)

__ Science: short-answer questions (20 minutes)

A sample checklist for daily work tasks:

__ 9 a.m. to 10 a.m.: Proposal project

__ 10 a.m. to 10:15 a.m.: Break

__ 10:15 a.m. to 11:45 a.m.: Meeting

__ 11:45 a.m. to 12:30 p.m.: Return phone calls/email

__ 12:30 p.m. to 1:30 p.m.: Lunch

__ 1:30 p.m. to 3 p.m.: Finish inventory

__ 3 p.m. to 4:30 p.m.: Review of accounts

__ 4:30 p.m. to 5 p.m.: Return phone calls/email

When creating a checklist, there are a few important things to keep in mind. First, make sure that the creation of a checklist does not take a large amount of time. Also be sure that the way the checklist is set up is easy to follow. It is important not to force the use of a specific checklist on a child, adolescent, or adult; this goes for most strategies and tools. Try to work collaboratively with the person, get his or her input, and figure out a compromise that includes his or her ideas. If you do this, an individual is more likely to use the checklist.

If you try a checklist and it doesn’t work well, examine what did not work. It may lead to revamping how the checklist is created, displayed, or used. In other situations, it may mean finding an alternative strategy.

dice bouncingWhen your gambling gets out of control, it can be extremely destructive and devastating to you and to those with whom you associate. Because a gambling addiction develops over time, you, your friends, and family members may not notice that your behavior is compulsive or getting out of hand. However, just because you gamble and enjoy gambling a lot does not mean you are addicted to it.

There are ways to determine whether certain behaviors and activities related to your gambling suggest that you are enjoying a recreational activity or if your gambling has become a compulsive habit with potentially serious consequences. As an addiction psychologist and certified addiction counselor in Pennsylvania, which recently bested New Jersey in combined gambling revenue for 2012 and 2013, many people come to me to find help sorting through the interrelated mental health issues that may fuel gambling behavior in order to determine whether they have a mild gambling problem, a major compulsive and pathological issue, or just an expensive hobby that is all in good fun.

It’s rare, but possible, to develop a gambling addiction after your very first gambling experience. When problems develop, they usually progress over time. Many people participate in social gambling for years with no problems. More frequent gambling or life stressors can contribute to social gambling becoming a serious problem. Most casual gamblers can stop gambling when they have to because of losses; they can set a loss limit and easily follow it. People with a compulsive gambling problem feel strong urges to keep gambling to recoup their lost money. When gamblers are betting to chase losses, things can tailspin out of control, gamblers can lose touch with reality, and the issue can manifest in severe and exacting consequences. Over time, this issue can become more and more destructive.

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For many compulsive gamblers, gambling is about the thrill, not the money. Some begin to take bigger risks and place larger bets to keep getting more of a thrill; this can take a financial toll. When a gambler is trying to recoup losses, lives can be destroyed. Many folks with whom I work recount that their bottom was when this shift happened and they realized that they were gambling in the hope they could get back their losses.

A gambling addiction, unlike drug or alcohol addictions, often has no obvious physical signs or symptoms. Many people with problematic gambling habits deny that they have a problem. They minimize the problem or refuse to admit that their gambling is out of control. They often gamble in secrecy, not allowing friends and family to know about their behavior. They may lie, keep secrets, sneak around, or completely withdraw socially. They do this to make it difficult for anyone to interfere with or confront them about their detrimental behavior.

An important part of recovery from a gambling issue is to expose the gambler’s secrets—extra credit cards, hidden cash, unaccounted-for time, lies about income, etc.—over time to the right, supportive people at the right times. A therapist is a great start, and meeting other people who are recovering from gambling addiction can help a person to feel understood, supported, and guided into long-term recovery.

Just as substance abuse is characterized by uncontrollable urges to consume a particular substance, causing negative consequences to the addicted person and those around the person, a gambling addiction is characterized broadly by tendencies to gamble in ways that cause damage to the person who is gambling and those associated with that person. The urge to gamble can be especially overwhelming during episodes of stress or depression. A person may use gambling as an unhealthy way to cope. As the problem develops and becomes stronger, a gambler may become overly focused on gambling (gambling-seeking) and getting money to gamble.

What Are the Risk Factors?

Certain factors may put you at greater risk for becoming addicted to gambling or having a harder time stopping. These include substance abuse (alcohol abuse is common), mood (often depression) or personality issues or attention-deficit hyperactivity (ADHD); age (younger and middle-aged); sex (women gamblers usually start later in life and tend to have depression, anxiety, or bipolar and can become addicted quicker, although these differences are disappearing); family influence (having a parent with a gambling issue increases your chances); certain medications such as those which treat Parkinson’s and restless leg syndrome (RLS), called dopamine agonists, may have a rare side effect that results in compulsive behaviors, including gambling; and certain personality characteristics such as being highly competitive, a workaholic, restless, or easily bored.

The National Council on Problem Gambling, referring to a Harvard study, estimates that two million (or 1% of) U.S. adults meet the criteria for compulsive gambling in a given year. Another four million to six million do not meet the full diagnostic criteria for compulsive gambling, but meet at least one of them and are experiencing problems due to their gambling behavior. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, a diagnosis of gambling disorder is made when someone meets at least four of the following nine criteria in a 12-month period:

  1. Tolerance: Needing larger wagers to experience the same “rush” (similar to the “rush” felt by drug users).
  2. Withdrawal: Restlessness or irritability when attempting to reduce or cease gambling.
  3. Loss of control: Repeated unsuccessful attempts to cut down or stop on his/her own.
  4. Preoccupation: Frequent thoughts about gambling experiences, whether past, future, or fantasy.
  5. Escape: Gambling to improve mood or escape problems.
  6. Chasing: Trying to win back gambling losses with more gambling.
  7. Lying: Hiding the extent of the behavior by lying to friends, family, or a therapist.
  8. Risked a significant relationship: Gambling despite damaging or losing an important relationship, job, or other significant opportunity.
  9. Bailout: Turning to friends, family, or a third party for financial assistance resulting from gambling activities.

Do You Have a Gambling Problem?

As with drug and alcohol abuse, it is often an indication that you have a problem if you are wondering whether you have a problem. If you are losing time from your everyday activities because you are gambling or thinking about gambling; spend more time gambling than you intended to; are gambling to escape worries or stave off boredom or loneliness; or spent money you needed to pay your bills or other expenses, you likely do have a gambling problem.

Are your friends and family expressing concern? They might be recognizing the ways in which your gambling is affecting you before you are. The sooner you seek help and treatment, the less damage to your finances, relationships, and work you will have to repair.

Would you like to stop? The first step to getting well is to accept that you have a progressive issue. It is so much easier to change when we want to, at least a little bit, and so much harder to change when we have to.

Quitting for a while or taking a break is a good indication that you have control over your gambling. It’s possible for some compulsive gamblers to go into remission where they gamble less or not at all. Without professional treatment, though, they will usually relapse.

Like other addictions, a gambling issue may wax and wane or come and go, just as different drugs become more in vogue depending on the zeitgeist. Many people who see me for addiction like to think of their compulsive behavior as the whack-a-mole game people play at carnivals. You can whack the mole, but it’s connected to something else and it will pop up again. It might pop up as a different gambling game, drug use, alcohol use, or shopping or food addiction. Whether it pops up in Atlantic City, Philadelphia, Las Vegas, or in a casino near you, gambling is here to stay, and so, too, is addiction. We must learn to live with these tendencies and become curious about how they work and what purpose they serve for us as individuals, our cultures, and society. With increased awareness and understanding, we can learn how to help ourselves and those we love and care about.

For help with an addiction issue, find a therapist.

Sleeping ChildSleep is not only important for your child’s rest and rejuvenation, good sleep is essential to healthy development. Sleep problems affect a child’s mood, ability to cope, and academic performance. Sufficient sleep can promote emotional resilience and keener senses.

Quality vs. Quantity

Sleep scientists tell us that preschoolers need 11 to 13 hours of sleep each night, while children ages 5 to 12 need 10 to 11 hours. Making sure your child gets enough sleep can be a demanding task, but it’s one that reaps almost instant rewards. Well-rested children learn better, play better, and even sleep better the next night.

However, sleep is gauged by both quantity and quality. Scientists view our nightly slumber in terms of the stages of brain-wave activity and physiology that punctuate the course of a night’s sleep. These stages progress in predictable patterns known as sleep cycles. Sleep quality is a way of evaluating the health of our sleep cycles.

Sleep Cycle

A typical sleep cycle starts when your child feels drowsy, resulting in light sleep. Next, he or she enters a longer period of deep sleep, which is followed by a shorter period of rapid eye movement (REM) sleep. He or she dreams during REM sleep, and then the cycle begins again, starting with drowsiness or very light sleep. Your child will go through four to six (or more) sleep cycles during the night.

If his or her sleep is disturbed mid-cycle, and/or he or she has incomplete sleep cycles, or if he or she sleeps too lightly or wakes too easily, his or her sleep quality will be poor, independent of number of hours of sleep. This may lead to mood swings and/or difficulty with concentration, and over time, long-term health can be threatened.

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Sleep Solutions

Here are five strategies that may help your child get the quantity and quality of sleep he or she needs:

1. Dim the lights.

Surprisingly, it’s not simply seeing light that wakes us in the morning. In fact, it is a specific wavelength of blue light that starts the process. Sunlight, as well as the light emitted by fluorescent bulbs, television, and computer and smart phone screens, contains blue wavelengths that trigger a waking response in our brains.

Exposing your child to these artificial light sources during the hour before bed can make falling asleep harder, and diminish the quality of sleep by curtailing the production of the sleep hormone melatonin. Even nonfluorescent lights can trigger this effect when the source is overhead, so avoiding the use of ceiling lights and tall floor lamps can help.

In place of watching nighttime TV and movies, have your child listen to stories. The tradition of reading bedtime stories out loud is perfect. If you are not in the mood to read, try an electronic book or gentle music.

For an older child who uses a computer or other electronics at night for homework, consider using an app or program that both dims screens at sunset and adjusts the output spectrum to include very little blue. The app will typically return the screen to its normal color mode and brightness at sunrise. The app described is shareware called f.lux.

2. Provide a calm environment.

A calming, soothing bedroom environment can be remarkably effective in helping your child fall asleep. To create a peaceful environment, reduce visual stimuli. If you are thinking of painting or redecorating, try using calm or soft colors. Set lamps on low bedside tables. Reducing clutter can help, too.

To provide a calm environment when siblings share a room, try a white-noise machine, or, if necessary, remove one child until the other can sleep well on his or her own.

If sleep is especially difficult to attain, stricter measures may be needed. Associating the bed with sleep can make a big difference and change how your child relates with his or her sleep environment. This entails pairing the bed with the activity of sleep, similar to how Ivan Pavlov paired a bell with meal time in his famous dog experiments.

Pairing the bed with sleep means that your child must use his or her bed only for sleeping—not to watch television in, eat in, or even play on. That way, whether he or she sees or lies in bed, his or her body will know the bed is meant for sleep. If sleep continues to be elusive, it may be time to seek the help of a licensed mental health or medical professional.

3. Establish a routine and stick with it.

A bedtime routine means consistently doing the same activities before bed, at or very close to the same time, every night. The activities can be as simple as teeth-brushing and pajama donning, as typical as a bedtime story, or as elaborate as a scented bath, followed by soothing music and a back massage. Whether simple or elaborate, a consistently applied routine will help your child have an easier time falling asleep and staying asleep.

A sleep routine also supports the circadian clock in your child’s brain. This is because over time your child’s brain associates the time of day and bedtime prep activities with sleep, so when the routine is started, the brain gears up for sleep while he or she completes the bedtime tasks.

One word of caution: a bedtime routine can be easier to establish than maintain. It helps if everyone in the household is on board. To set the stage for success, create a sleep schedule that can be consistently manageable, even if a parent is absent or the child is away from home.

An optimal routine starts the countdown between 30 and 60 minutes before bedtime. Timing is basic to routines, and while some flexibility is great, keeping bedtime at 9 p.m. or earlier is strongly recommended for children 12 and younger.

4. Substitute soda or hot chocolate with chamomile tea or warm milk.

What goes into your child’s body can impact how he or she sleeps, and understanding how different foods impact sleep can have life-long benefits.

Chamomile tea and warm milk each have ingredients that promote relaxation. Even if your child can fall asleep after drinking caffeine, his or her sleep cycles may not be as complete.

Teach your child to understand and respect his or her body. A healthy body supports healthy sleep. For example, he or she may need exercise during the day in order to sleep well at night.

Also, naps count. If your child still needs a nap, to have real value the nap must be at the right time. An optimal duration and time for napping is about 30 minutes between 2 p.m. and 5 p.m. Avoid napping between 7 a.m. and noon or after 6 p.m.

5. Teach your child how to self-soothe and relax.

Children get stressed too, and worries or tension can make it difficult to fall and stay asleep. In part, this is because stress is correlated with high cortisol levels, and high cortisol can inhibit sleep. However, when your child’s body moves into a relaxed state, cortisol levels reduce.

A healthy bedtime routine can reduce anxiety associated with sleep. Soothing and relaxation exercises don’t need to take a lot of time out of the routine. Adding just five to 10 minutes of a relaxing activity can make a difference. Relaxation techniques can include a muscle tension/relaxation exercise, a guided visualization, or listening to gentle music.

Massage and similar modalities can also help (for some children, a back rub is always welcome). Likewise, warm baths have long been believed to help induce asleep, and they’re a great part of the bedtime routine.

There’s another benefit to bedtime baths. They’re not only a way to keep your child clean and cozy, science has shown that a result of bathing is a drop in core body temperature, which helps to start the sleep cycle. An ideal bath time is first on the routine, at least an hour prior to sleep, so that your child’s body has time to cool down before he or she hits the sheets.

Research has demonstrated that a lavender scent can be effective at promoting relaxation, and thus works as a sleep aid. Try a drop of lavender essential oil in the bath water, or place a few on drops on the shower floor (scent will rise).

References:

  1. Abbott, S. M., Arnold, J. M., Chang, Q., Miao, H., Ota, N., Cecala, C., … Gillette, M. (2013, August). Signals from the Brainstem Sleep/Wake Centers Regulate Behavioral Timing via the Circadian Clock. PLoS ONE, 8(8), 1-11.
  2. BBC Worldwide Ltd. (2009). Films on Demand collection. 10 things you should know about sleep.
  3. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006. 2, Sleep Physiology. RetrievedAugust 16, 2014, from: http://www.ncbi.nlm.nih.gov/books/NBK19956/
  4. Meltzer, L. (2010, Jul-Sep). Key procedural elements for the treatment of behavioral insomnia of childhood. Chart. Behavioral Sleep Medicine, 8(3), 177.
  5. Mindell, J. A., Meltzer, L. J., Carskadon, M. A., Chervin, R. D. (2009, August). Developmental Aspects of Sleep Hygiene: Findings from the 2004 National Sleep Foundation Sleep in America Poll. Sleep Medicine, 10(7), 771-779.
  6. National Sleep Foundation (2014). Children and Sleep. Retrieved August 13, 2014, from http://sleepfoundation.org/sleep-topics/children-and-sleep

Woman sitting in chair with notepad on her lap, looking into the distance

Cost is one of the greatest barriers to mental health treatment. Although the Affordable Care Act and other regulatory reforms sought to improve access to behavioral and mental health services, many people worry about the costs of therapy. While the cost of therapy is a very real concern, it is often possible for people to access free or low-cost therapy, especially if they live in large metropolitan areas or near a teaching university.

WHAT IS THE AVERAGE COST OF THERAPY?

Therapy generally ranges from $65 per hour to $250 or more. In most areas of the country, a person can expect to pay $100-$200 per session. Some factors that can affect the price of therapy include:

Some therapists also charge more for a longer initial consultation.

HOW MUCH DOES THERAPY COST WITH INSURANCE?

Under the Affordable Care Act, all insurance plans must cover mental health care. Additionally, plans must not impose different rules on mental health clients or fund mental health care at lower rates.

When people pay for therapy through insurance, they typically must pay a co-pay. Insurance co-pays vary widely, from just a few dollars to $50 or more.

This means people with insurance usually have some coverage for therapy. In most cases, they must choose a therapist within their network. They may also have to meet other criteria, such as having a mental health diagnosis, meeting a deductible, or getting a referral for treatment. Consequently, even people with insurance may opt to pay for their therapy out of pocket.

Search for a therapist in Los Angeles, or one of our other popular cites.

HOW TO PAY FOR THERAPY

For many people, insurance offers the best option for funding therapy. Try calling your insurer to ask about mental health coverage and to get a list of in-network providers.

If you don’t have insurance, you may be eligible for insurance through your state’s Medicaid program or through the Healthcare.gov marketplace.

Some employee assistance and benefit programs also offer help paying for therapy.

Many universities offer free or sliding-scale therapy programs to people pursuing training as therapists. Try calling schools near you to ask about access to low-cost therapy.

Additionally, some therapists offer therapy on a sliding-scale basis. Consider asking about this option when you interview therapists. Some therapists may also offer payment plans that allow you to pay for therapy over time.

Many therapy practices also employ novice therapists who need experience. These interns or apprentices may offer free or low-cost mental health care.

Telehealth services, which offer counseling online or on the phone, may also be more affordable.

IS THERE A WAY TO GET FREE THERAPY?

A number of clinics are working to expand access to health care services, including mental health services, by offering free or discounted treatment. The National Association for Free and Charitable Clinics, for example, offers free and low-cost care.

Some other options for finding free therapy in your area include:

WHAT THERAPISTS SAY ABOUT THE COSTS OF THERAPY

Woman patient smiling while practicing growth oriented psychotherapy

Lisa M. Vallejos, MA, LPC, NCC: Therapy costs have an extremely wide range. I know clinics that charge as little at $5 per session and others that charge $300 per session. It really is dependent on the therapist, your location, and the going rate for therapy in your area. There are many things to consider in addition to the cost that I would like to address.

Another factor to consider is whether you plan on using your insurance for therapy. In that case, you will likely be limited to however many sessions your insurance will pay for, which can vary. Also to consider if you are using your insurance, is whether there are only certain types of therapy that are covered, such as cognitive behavioral therapy. If you are paying for therapy with insurance, also consider that to be covered by insurance you must have a “covered” diagnosis. Your therapist will diagnose you and will list that diagnosis on your reimbursement paperwork. You will likely have a co-pay to pay when you seek insurance-reimbursed therapy, so be sure to find out how much that is as well.

Many therapists elect not to take insurance to avoid having to diagnose and the challenges that come with working with insurance companies, so it may be worth your while to ask the potential therapist to work with you on a fee that you can afford to bypass insurance.

Finally, many therapists will work on a sliding fee scale, but they do not always advertise that. A sliding scale is a payment structure that is based on your income. You can ask your potential therapist if they do, and if they do not, would they consider doing it for you.

Marla B. Cohen, PsyD: The price of therapy varies. Many insurance plans cover psychotherapy, and if you choose to work with a provider within your network, you will only need to pay your typical co-payment. Should you choose to see a therapist outside of your insurance network, you will find that therapists charge different rates depending on their office location, level of education, and degree of expertise in their field.

Some therapists may charge as much as $200 or more per session, but most will charge $75-$150 a session. Many therapists work with a sliding scale fee schedule, which means their fee will depend on your income level. If you have out-of-network benefits with your insurance plan, you may be reimbursed for the majority of what you pay the therapist. Your therapist’s office can create a ledger for you to submit to your insurance company for reimbursement. If costs are an issue, many areas have community mental health agencies that provide therapy at a reduced fee.

Stacey Fuller, LMFT: When it comes to the cost of therapy, there is no set industry standard. The cost of therapy can vary widely depending on a number of factors.

Some therapists are part of a panel of providers who accept a particular insurance. In this case, the cost of therapy may only be a co-pay and/or deductible payment determined by the insurance company. Typically, insurance companies will limit the number of sessions they pay for in a calendar year so it is important to check with your insurance provider prior to initiating therapy to determine how much of the cost of treatment will be covered.

Some therapists choose to not accept insurance and instead offer fee-for-service (otherwise known as private pay) only. How private pay therapists set their rates is dependent on a number of factors: area, specialization and specialized training, number of years of experience, how in demand they are in the community, etc. In my area private pay therapists are typically priced anywhere from $65 on up to $250 a session. In other areas of the country, the prices may be quite different. Checking out some GoodTherapy therapist profiles in your area will give you a general sense of the cost of private pay therapy.

Free or low-cost therapy is often available for people with limited financial means through local clinics, hospitals, and community agencies. Frequently these providers are students in training or mental health interns who provide therapy at a low rate or free of charge in exchange for experience hours towards licensure.

GETTING HELP

Therapy can be expensive, particularly when you look only at the price tag and not the total value. Yet therapy can also confer significant benefits, including an improved financial outlook or better career prospects. People who are less productive because of depression, who suffer from creative blocks, who struggle to identify the right career path, who engage in compulsive shopping or gambling, and who experience problems at work may ultimately have more money as a result of therapy. Even when therapy does not offer a direct economic benefit, it can greatly and permanently improve a person’s life.

People considering therapy should consider the overall value of therapy, not just the cost. To find a therapist who can bring real value to your life, click here.

References:

  1. Gold, J. (2017, November 30). Health insurers are still skimping on mental health coverage. Retrieved from https://www.npr.org/sections/health-shots/2017/11/29/567264925/health-insurers-are-still-skimping-on-mental-health-coverage
  2. Mental health and substance abuse health coverage options. (n.d.). Retrieved from https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage
  3. Rowan, K., Mcalpine, D. D., & Blewett, L. A. (2013). Access and cost barriers to mental health care by insurance status, 1999-2010. Health Affairs, 32(10), 1723-1730. doi: 10.1377/hlthaff.2013.0133
Important Notice

GoodTherapy is not intended to be a substitute for professional advice, diagnosis, medical treatment, or therapy. Always seek the advice of your physician or qualified mental health provider with any questions you may have regarding any mental health symptom or medical condition. Never disregard professional psychological or medical advice nor delay in seeking professional advice or treatment because of something you have read on GoodTherapy.