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Helping patients heal after a bruising election campaign
One of us practices in the “new south” community of Charlotte, N.C., “a red state”; the other is in the “blue bubble” of Washington. In our respective polarized zones, the divergent reactions we heard about the presidential candidates were akin to projective responses to Rorschach tests.
As mental health clinicians, we knew that the country was wounded and in need of healing long before the outcome of the unconventional and acrimonious 2016 American presidential race. So, we were concerned about how patients, clinicians, and divergent communities would go about healing after an 18-month pre-election slugfest that revealed bigotry that persists more than 150 years after the Civil War.
Background of ‘two sides’
None of the nasty rhetoric delivered by our now president-elect or the clearly defensive responses we heard from our former secretary of state were going to be easily forgotten after Nov. 8, 2016. As the process unfolded, however, the voice of psychiatry, with some notable exceptions (the blog of Justin Frank, MD, for example), was absent from the public dialogue.
Nevertheless, writing in June of this year, Bill Moyers and Michael Winship summed up the private assessment of many professionals and the fears for many of a Trump presidency:
There is a virus infecting our politics and right now it’s flourishing with a scarlet fever. It feeds on fear, paranoia and bigotry. All that was required for it to spread was a timely opportunity – and an opportunist with no scruples. ... There have been stretches of history when this virus lay dormant. ... Today its carrier is Donald Trump, but others came before him: narcissistic demagogues who lie and distort in pursuit of power and self-promotion. Bullies all, swaggering across the landscape with fistfuls of false promises, smears, innuendo and hatred for others, spite and spittle for anyone of a different race, faith, gender, or nationality.1
Alternatively, some had a smoldering fear of the progressive agenda to bring “others” – more women, African Americans, Latinos, the LGBTQ community, Muslims, and the disabled – securely under the tent of American democracy. Others, especially the underemployed cohort in neglected and struggling communities in Middle America, were simply opposed to a continuation of “politics as usual,” a.k.a. Hillary Clinton, and were desperate for change.
The opposition views were summed up in the innuendo of the slogan: “Make America Great Again.” By the election, the tensions had begun to resemble the aggressive spirit of a sporting event: It’s “us” versus “them.”
Causes of concern
In the months leading up to the election, violent events strained the societal divisions. The police use of force2 resulted in the near-daily deaths of African American men and women and other people of color at the hands of police officers. The events built on a long and growing list of violent acts – the racially motivated shootings of nine men and women in a Charleston, S.C., church, the bombing injuries and deaths at the Boston Marathon, the shooting deaths of 20 children and 6 adults at Sandy Hook Elementary School, the homophobia-motivated shootings in a Florida nightclub – that have heightened levels of fear, anxiety, and concern for personal and family safety. For many, life has felt fragile and out of control, the perfect setup to motivate the electorate to cast their votes for the person they imagined had the most power and most interest in restoring their sense of control over their lives and, ultimately, their sense of safety.
Why the fear? A psychodynamic analysis
As psychiatrists trained in psychodynamic theory, we are quite familiar with the concept of identifying with the aggressor as a means of coping. The classic example is when a child watches his or her parents in an abusive relationship and identifies with the abusive parent in an attempt to avoid identifying with the victimized parent.
This dynamic is one that seems to have played out during this presidential election. By October 2016, Donald J. Trump already reportedly had insulted more than 280 people, places, and things on Twitter.3 Despite the evidence that Mr. Trump verbally bullied not only his opponents, but also the media, Latinos, women, the LGBTQ community, the Republican Party (his claimed party), and Muslims, people came out in numbers high enough to make him America’s president-elect. In the classic process of bullying his perceived enemies, those considered “the other,” he assigned names such as “crooked Hillary,” “little Marco,” and “lyin’ Ted” – just as a bully at school assigns names to the kid he’s decided does not have enough worth to be called by his given name.
He depicted women who accused him of sexual assault as either not being pretty enough to be worthy of assault or self-serving in their public accusations. Mexicans entering this country were referred to as “rapists and thugs.” African Americans were told that their lives are so bad that they “have nothing to lose” if they voted for a candidate who talked about erecting a wall to block out other people of color, and changing immigration laws that would banish an entire religion from entering our country.
The ‘blue bubble’ – Those who voted for Mrs. Clinton
So … this happened. And, in our consulting rooms, we are seeing a stark increase in the numbers of individuals, couples, and families reporting overwhelming anxiety, sadness, and a sense of de-realization (“it’s surreal”). At the core of their anxiety is concern for self, family, and friends as well as concern for the country as a whole.
The post-election notions that families would be immediately broken up, parents deported, the Affordable Care Act immediately dismantled, and countries bombed immediately after Election Day did not become realities. However, there is valid reason to be concerned. The Southern Poverty Law Center has noted a significant increase in post-election hate crimes throughout the nation.4
The new South ‘red states’ – those who voted for Mr. Trump
Trump supporters are feeling victorious because their “underdog” candidate ran an unconventional presidential campaign and won. However, some who voted for Mr. Trump will at some point experience anxiety when the excitement of “winning” wears off. Psychoanalyst Justin Frank speaks to this and more in his Nov. 9, 2016, blog in which he concludes: “While we mourn and blame others and ourselves for our American tragedy, Trump voters must eventually look at themselves in the mirror and exclaim, ‘what have we done?’ ”5
In his Oct. 25, 2016, New York Times article, Michael Barbaro summarized the behaviors that will become increasingly of concern to all as Mr. Trump accepts the oath of office:
The intense ambitions and undisciplined behaviors of Mr. Trump have confounded even those close to him.... In interviews, Mr. Trump makes clear just how difficult it is for him to imagine – let alone accept – defeat....
“I never had a failure,” Mr. Trump said in one of the interviews, despite his repeated corporate bankruptcies and business setbacks, “because I always turned a failure into a success.”6
This fundamental inability to accept responsibility and the attempt to distort reality is something that must concern each of us, regardless of our ideological differences.
Distress tolerance as a model for healing
Even before the outcome of the election, we were hearing from patients who did not feel safe and who reported being “terrified” about what our country might become. This is where a focus on processing the pain and decreasing anxiety is necessary. This is not an anxiety we can medicate with anxiolytics or rationalize by telling ourselves and our patients that the best man won “fair and square.” We have each – by this time – experienced patients who are quite shaken by this turn of events.
Although it has not received much press, many consider Mr. Trump’s victory to be, in part, a “white backlash.” Many supporters of Mr. Trump have felt too ashamed to publicly admit their support for a candidate who at least by innuendo incited fear, anger, and violence. This failure has created an anxiety reminiscent of the daytime anxiety experienced by people who survived nighttime lynchings in small Southern towns. The day after the lynching, it was not unusual for African American men, women, and children to wonder if their grocer, banker, postal carrier, or sheriff had donned a white hood the night before and lynched someone in their community.
The question of survival, how to survive the unimaginable, is what most distresses people. They’ve wondered out loud whether they, their family, and friends would be attacked and/or killed by those who now feel emboldened and authorized to act on their latent aggressive impulses. And, our patients’ fears are legitimate because, unfortunately, studies show that verbal aggression is correlated with increased risk of physical violence and even murder.7
In the dialectical behavioral therapy (DBT) construct developed by Marsha M. Linehan, PhD, the goals of distress tolerance are crisis survival, reality acceptance, and then freedom.8
As we apply our skills, we are uniquely positioned to help our patients and their families survive this crisis, accept that this is our president-elect, and ultimately be free from the anxiety created by the behavior that we all witnessed. We can aid in the navigation through this storm.
Acceptance
We’re already on to reality acceptance. The reality that so many African Americans and people of color have been living is now known and experienced by many who had felt immune to being marginalized. They now understand the loss of security that accompanies overwhelming fear of being the object of verbal, emotional, and physical aggression and violence.
Some are coping by entertaining fantasies that this election outcome will be undone, that the Electoral College will not approve our president-elect when it meets on Dec. 19 or that Mr. Trump will be impeached early in this upcoming term. The results of the presidential election are unlikely to be undone, so having more than 2 months between Election Day and the inauguration to work on acceptance will be helpful. The goal here is to accept the past, be hopeful about the future, and be vigilant in the present.
Freedom
Now, on to freedom. Our goal is to have all of our patients, families, colleagues, and communities able to live without fear that our leaders are not able to apply humanitarian principles to keep all of us safe. The next few months are crucial. Americans must speak out and debride the wound that bullying intentionally causes. Just as with a school bully, Mr. Trump’s behavior has to be called what it is, not sugarcoated or normalized.
History is full of critical moments in time in which, even in our fear, we said nothing. Even the most empathic of us watched the bully at school and felt relief that his behavior was not directed toward us. But we must not avert our gaze.
Bill Moyers and Michael Winship compared Mr. Trump to Sen. Joseph McCarthy, whose reign of terror was ended when journalist Edward R. Murrow courageously spoke out in defiance of the senator. At the end of one of his segments on “See It Now,” Mr. Murrow concluded as he signed off:
We will not walk in fear, one of another. We will not be driven by fear into an age of unreason, if we dig deep in our history and our doctrine, and remember that we are not descended from fearful men — not from men who feared to write, to speak, to associate and to defend causes that were, for the moment, unpopular.9
And, so, how do we cope?
Fortunately, we understand bullying. The bully doesn’t take over the entire school and won’t have the power to take over one’s entire life if the behavior is brought out in the open and openly discussed. But bullies need to accept responsibility, which is what Sen. Harry Reid of Nevada and other legislators urged President-elect Trump to do in days immediately following the election.10 They have called on him to discourage the fear, anger, and violence leading up to and following the election. This action on Mr. Trump’s part would promote a vitally needed national healing process.
Ultimately, this is “the land of the free, the home of the brave …” and we will do what we have always done as psychiatrists and mental health professionals who help to heal wounds. Not all of us will participate in social justice initiatives. However, each of us can listen with intense compassion and interest to those with whom we identify politically and to those whose views diverge from our own. This is our most potent tool in a conflict where we don’t understand the motives of unpredictable leaders or their followers. It is only with this skilled listening that a space is created in which each “other” hears the “other.” This is where real healing begins.
The views expressed in this article are solely those of the authors, and are not meant to represent the views of the American Psychiatric Association, Novant Health, Clinical Psychiatry News, or any other organization.
References
1. http://billposters/story/trump-virus-dark-age-unreason
2. http://blackdoctor.org/495036/national-medical-association-statement-on-police-use-of-force
3. http://www.nytimes.com/interactive/2016/01/28/upshot/donald-trump-twitter-insults.html?_r=0
4. https://www.splcenter.org/hatewatch/2016/11/11/over-200-incidents-hateful-harassment-and-intimidation-election-day
5. http://www.obamaonthecouch.com
6. http://www.nytimes.com/2016/10/26/us/politics/donald-trump-interviews.html
7. “The Nature of Prejudice,” (New York: Perseus Books Publishing, 1979).
8. DBT® Skills Training Handouts and Worksheets, Second Edition (New York: The Guilford Press, 2014).
9. http://billmoyers.com/story/trump-virus-dark-age-unreason
10. http://www.reid.senate.gov/press_releases/2016-11-11-reid-statement-on-the-election-of-donald-trump#.WC0iA6IrKgR
Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is the immediate past president of the Washington Psychiatric Society, and associate clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics. Dr. Ifill-Taylor, a child, adolescent, and adult psychiatrist, is in practice as a medical director in Charlotte, N.C. Previously, she was in private practice in the Washington area and worked as a staff psychiatrist for the Department of Veterans Affairs. She is particularly interested in the effect of our social, political, and occupational environment on mental and physical health.
One of us practices in the “new south” community of Charlotte, N.C., “a red state”; the other is in the “blue bubble” of Washington. In our respective polarized zones, the divergent reactions we heard about the presidential candidates were akin to projective responses to Rorschach tests.
As mental health clinicians, we knew that the country was wounded and in need of healing long before the outcome of the unconventional and acrimonious 2016 American presidential race. So, we were concerned about how patients, clinicians, and divergent communities would go about healing after an 18-month pre-election slugfest that revealed bigotry that persists more than 150 years after the Civil War.
Background of ‘two sides’
None of the nasty rhetoric delivered by our now president-elect or the clearly defensive responses we heard from our former secretary of state were going to be easily forgotten after Nov. 8, 2016. As the process unfolded, however, the voice of psychiatry, with some notable exceptions (the blog of Justin Frank, MD, for example), was absent from the public dialogue.
Nevertheless, writing in June of this year, Bill Moyers and Michael Winship summed up the private assessment of many professionals and the fears for many of a Trump presidency:
There is a virus infecting our politics and right now it’s flourishing with a scarlet fever. It feeds on fear, paranoia and bigotry. All that was required for it to spread was a timely opportunity – and an opportunist with no scruples. ... There have been stretches of history when this virus lay dormant. ... Today its carrier is Donald Trump, but others came before him: narcissistic demagogues who lie and distort in pursuit of power and self-promotion. Bullies all, swaggering across the landscape with fistfuls of false promises, smears, innuendo and hatred for others, spite and spittle for anyone of a different race, faith, gender, or nationality.1
Alternatively, some had a smoldering fear of the progressive agenda to bring “others” – more women, African Americans, Latinos, the LGBTQ community, Muslims, and the disabled – securely under the tent of American democracy. Others, especially the underemployed cohort in neglected and struggling communities in Middle America, were simply opposed to a continuation of “politics as usual,” a.k.a. Hillary Clinton, and were desperate for change.
The opposition views were summed up in the innuendo of the slogan: “Make America Great Again.” By the election, the tensions had begun to resemble the aggressive spirit of a sporting event: It’s “us” versus “them.”
Causes of concern
In the months leading up to the election, violent events strained the societal divisions. The police use of force2 resulted in the near-daily deaths of African American men and women and other people of color at the hands of police officers. The events built on a long and growing list of violent acts – the racially motivated shootings of nine men and women in a Charleston, S.C., church, the bombing injuries and deaths at the Boston Marathon, the shooting deaths of 20 children and 6 adults at Sandy Hook Elementary School, the homophobia-motivated shootings in a Florida nightclub – that have heightened levels of fear, anxiety, and concern for personal and family safety. For many, life has felt fragile and out of control, the perfect setup to motivate the electorate to cast their votes for the person they imagined had the most power and most interest in restoring their sense of control over their lives and, ultimately, their sense of safety.
Why the fear? A psychodynamic analysis
As psychiatrists trained in psychodynamic theory, we are quite familiar with the concept of identifying with the aggressor as a means of coping. The classic example is when a child watches his or her parents in an abusive relationship and identifies with the abusive parent in an attempt to avoid identifying with the victimized parent.
This dynamic is one that seems to have played out during this presidential election. By October 2016, Donald J. Trump already reportedly had insulted more than 280 people, places, and things on Twitter.3 Despite the evidence that Mr. Trump verbally bullied not only his opponents, but also the media, Latinos, women, the LGBTQ community, the Republican Party (his claimed party), and Muslims, people came out in numbers high enough to make him America’s president-elect. In the classic process of bullying his perceived enemies, those considered “the other,” he assigned names such as “crooked Hillary,” “little Marco,” and “lyin’ Ted” – just as a bully at school assigns names to the kid he’s decided does not have enough worth to be called by his given name.
He depicted women who accused him of sexual assault as either not being pretty enough to be worthy of assault or self-serving in their public accusations. Mexicans entering this country were referred to as “rapists and thugs.” African Americans were told that their lives are so bad that they “have nothing to lose” if they voted for a candidate who talked about erecting a wall to block out other people of color, and changing immigration laws that would banish an entire religion from entering our country.
The ‘blue bubble’ – Those who voted for Mrs. Clinton
So … this happened. And, in our consulting rooms, we are seeing a stark increase in the numbers of individuals, couples, and families reporting overwhelming anxiety, sadness, and a sense of de-realization (“it’s surreal”). At the core of their anxiety is concern for self, family, and friends as well as concern for the country as a whole.
The post-election notions that families would be immediately broken up, parents deported, the Affordable Care Act immediately dismantled, and countries bombed immediately after Election Day did not become realities. However, there is valid reason to be concerned. The Southern Poverty Law Center has noted a significant increase in post-election hate crimes throughout the nation.4
The new South ‘red states’ – those who voted for Mr. Trump
Trump supporters are feeling victorious because their “underdog” candidate ran an unconventional presidential campaign and won. However, some who voted for Mr. Trump will at some point experience anxiety when the excitement of “winning” wears off. Psychoanalyst Justin Frank speaks to this and more in his Nov. 9, 2016, blog in which he concludes: “While we mourn and blame others and ourselves for our American tragedy, Trump voters must eventually look at themselves in the mirror and exclaim, ‘what have we done?’ ”5
In his Oct. 25, 2016, New York Times article, Michael Barbaro summarized the behaviors that will become increasingly of concern to all as Mr. Trump accepts the oath of office:
The intense ambitions and undisciplined behaviors of Mr. Trump have confounded even those close to him.... In interviews, Mr. Trump makes clear just how difficult it is for him to imagine – let alone accept – defeat....
“I never had a failure,” Mr. Trump said in one of the interviews, despite his repeated corporate bankruptcies and business setbacks, “because I always turned a failure into a success.”6
This fundamental inability to accept responsibility and the attempt to distort reality is something that must concern each of us, regardless of our ideological differences.
Distress tolerance as a model for healing
Even before the outcome of the election, we were hearing from patients who did not feel safe and who reported being “terrified” about what our country might become. This is where a focus on processing the pain and decreasing anxiety is necessary. This is not an anxiety we can medicate with anxiolytics or rationalize by telling ourselves and our patients that the best man won “fair and square.” We have each – by this time – experienced patients who are quite shaken by this turn of events.
Although it has not received much press, many consider Mr. Trump’s victory to be, in part, a “white backlash.” Many supporters of Mr. Trump have felt too ashamed to publicly admit their support for a candidate who at least by innuendo incited fear, anger, and violence. This failure has created an anxiety reminiscent of the daytime anxiety experienced by people who survived nighttime lynchings in small Southern towns. The day after the lynching, it was not unusual for African American men, women, and children to wonder if their grocer, banker, postal carrier, or sheriff had donned a white hood the night before and lynched someone in their community.
The question of survival, how to survive the unimaginable, is what most distresses people. They’ve wondered out loud whether they, their family, and friends would be attacked and/or killed by those who now feel emboldened and authorized to act on their latent aggressive impulses. And, our patients’ fears are legitimate because, unfortunately, studies show that verbal aggression is correlated with increased risk of physical violence and even murder.7
In the dialectical behavioral therapy (DBT) construct developed by Marsha M. Linehan, PhD, the goals of distress tolerance are crisis survival, reality acceptance, and then freedom.8
As we apply our skills, we are uniquely positioned to help our patients and their families survive this crisis, accept that this is our president-elect, and ultimately be free from the anxiety created by the behavior that we all witnessed. We can aid in the navigation through this storm.
Acceptance
We’re already on to reality acceptance. The reality that so many African Americans and people of color have been living is now known and experienced by many who had felt immune to being marginalized. They now understand the loss of security that accompanies overwhelming fear of being the object of verbal, emotional, and physical aggression and violence.
Some are coping by entertaining fantasies that this election outcome will be undone, that the Electoral College will not approve our president-elect when it meets on Dec. 19 or that Mr. Trump will be impeached early in this upcoming term. The results of the presidential election are unlikely to be undone, so having more than 2 months between Election Day and the inauguration to work on acceptance will be helpful. The goal here is to accept the past, be hopeful about the future, and be vigilant in the present.
Freedom
Now, on to freedom. Our goal is to have all of our patients, families, colleagues, and communities able to live without fear that our leaders are not able to apply humanitarian principles to keep all of us safe. The next few months are crucial. Americans must speak out and debride the wound that bullying intentionally causes. Just as with a school bully, Mr. Trump’s behavior has to be called what it is, not sugarcoated or normalized.
History is full of critical moments in time in which, even in our fear, we said nothing. Even the most empathic of us watched the bully at school and felt relief that his behavior was not directed toward us. But we must not avert our gaze.
Bill Moyers and Michael Winship compared Mr. Trump to Sen. Joseph McCarthy, whose reign of terror was ended when journalist Edward R. Murrow courageously spoke out in defiance of the senator. At the end of one of his segments on “See It Now,” Mr. Murrow concluded as he signed off:
We will not walk in fear, one of another. We will not be driven by fear into an age of unreason, if we dig deep in our history and our doctrine, and remember that we are not descended from fearful men — not from men who feared to write, to speak, to associate and to defend causes that were, for the moment, unpopular.9
And, so, how do we cope?
Fortunately, we understand bullying. The bully doesn’t take over the entire school and won’t have the power to take over one’s entire life if the behavior is brought out in the open and openly discussed. But bullies need to accept responsibility, which is what Sen. Harry Reid of Nevada and other legislators urged President-elect Trump to do in days immediately following the election.10 They have called on him to discourage the fear, anger, and violence leading up to and following the election. This action on Mr. Trump’s part would promote a vitally needed national healing process.
Ultimately, this is “the land of the free, the home of the brave …” and we will do what we have always done as psychiatrists and mental health professionals who help to heal wounds. Not all of us will participate in social justice initiatives. However, each of us can listen with intense compassion and interest to those with whom we identify politically and to those whose views diverge from our own. This is our most potent tool in a conflict where we don’t understand the motives of unpredictable leaders or their followers. It is only with this skilled listening that a space is created in which each “other” hears the “other.” This is where real healing begins.
The views expressed in this article are solely those of the authors, and are not meant to represent the views of the American Psychiatric Association, Novant Health, Clinical Psychiatry News, or any other organization.
References
1. http://billposters/story/trump-virus-dark-age-unreason
2. http://blackdoctor.org/495036/national-medical-association-statement-on-police-use-of-force
3. http://www.nytimes.com/interactive/2016/01/28/upshot/donald-trump-twitter-insults.html?_r=0
4. https://www.splcenter.org/hatewatch/2016/11/11/over-200-incidents-hateful-harassment-and-intimidation-election-day
5. http://www.obamaonthecouch.com
6. http://www.nytimes.com/2016/10/26/us/politics/donald-trump-interviews.html
7. “The Nature of Prejudice,” (New York: Perseus Books Publishing, 1979).
8. DBT® Skills Training Handouts and Worksheets, Second Edition (New York: The Guilford Press, 2014).
9. http://billmoyers.com/story/trump-virus-dark-age-unreason
10. http://www.reid.senate.gov/press_releases/2016-11-11-reid-statement-on-the-election-of-donald-trump#.WC0iA6IrKgR
Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is the immediate past president of the Washington Psychiatric Society, and associate clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics. Dr. Ifill-Taylor, a child, adolescent, and adult psychiatrist, is in practice as a medical director in Charlotte, N.C. Previously, she was in private practice in the Washington area and worked as a staff psychiatrist for the Department of Veterans Affairs. She is particularly interested in the effect of our social, political, and occupational environment on mental and physical health.
One of us practices in the “new south” community of Charlotte, N.C., “a red state”; the other is in the “blue bubble” of Washington. In our respective polarized zones, the divergent reactions we heard about the presidential candidates were akin to projective responses to Rorschach tests.
As mental health clinicians, we knew that the country was wounded and in need of healing long before the outcome of the unconventional and acrimonious 2016 American presidential race. So, we were concerned about how patients, clinicians, and divergent communities would go about healing after an 18-month pre-election slugfest that revealed bigotry that persists more than 150 years after the Civil War.
Background of ‘two sides’
None of the nasty rhetoric delivered by our now president-elect or the clearly defensive responses we heard from our former secretary of state were going to be easily forgotten after Nov. 8, 2016. As the process unfolded, however, the voice of psychiatry, with some notable exceptions (the blog of Justin Frank, MD, for example), was absent from the public dialogue.
Nevertheless, writing in June of this year, Bill Moyers and Michael Winship summed up the private assessment of many professionals and the fears for many of a Trump presidency:
There is a virus infecting our politics and right now it’s flourishing with a scarlet fever. It feeds on fear, paranoia and bigotry. All that was required for it to spread was a timely opportunity – and an opportunist with no scruples. ... There have been stretches of history when this virus lay dormant. ... Today its carrier is Donald Trump, but others came before him: narcissistic demagogues who lie and distort in pursuit of power and self-promotion. Bullies all, swaggering across the landscape with fistfuls of false promises, smears, innuendo and hatred for others, spite and spittle for anyone of a different race, faith, gender, or nationality.1
Alternatively, some had a smoldering fear of the progressive agenda to bring “others” – more women, African Americans, Latinos, the LGBTQ community, Muslims, and the disabled – securely under the tent of American democracy. Others, especially the underemployed cohort in neglected and struggling communities in Middle America, were simply opposed to a continuation of “politics as usual,” a.k.a. Hillary Clinton, and were desperate for change.
The opposition views were summed up in the innuendo of the slogan: “Make America Great Again.” By the election, the tensions had begun to resemble the aggressive spirit of a sporting event: It’s “us” versus “them.”
Causes of concern
In the months leading up to the election, violent events strained the societal divisions. The police use of force2 resulted in the near-daily deaths of African American men and women and other people of color at the hands of police officers. The events built on a long and growing list of violent acts – the racially motivated shootings of nine men and women in a Charleston, S.C., church, the bombing injuries and deaths at the Boston Marathon, the shooting deaths of 20 children and 6 adults at Sandy Hook Elementary School, the homophobia-motivated shootings in a Florida nightclub – that have heightened levels of fear, anxiety, and concern for personal and family safety. For many, life has felt fragile and out of control, the perfect setup to motivate the electorate to cast their votes for the person they imagined had the most power and most interest in restoring their sense of control over their lives and, ultimately, their sense of safety.
Why the fear? A psychodynamic analysis
As psychiatrists trained in psychodynamic theory, we are quite familiar with the concept of identifying with the aggressor as a means of coping. The classic example is when a child watches his or her parents in an abusive relationship and identifies with the abusive parent in an attempt to avoid identifying with the victimized parent.
This dynamic is one that seems to have played out during this presidential election. By October 2016, Donald J. Trump already reportedly had insulted more than 280 people, places, and things on Twitter.3 Despite the evidence that Mr. Trump verbally bullied not only his opponents, but also the media, Latinos, women, the LGBTQ community, the Republican Party (his claimed party), and Muslims, people came out in numbers high enough to make him America’s president-elect. In the classic process of bullying his perceived enemies, those considered “the other,” he assigned names such as “crooked Hillary,” “little Marco,” and “lyin’ Ted” – just as a bully at school assigns names to the kid he’s decided does not have enough worth to be called by his given name.
He depicted women who accused him of sexual assault as either not being pretty enough to be worthy of assault or self-serving in their public accusations. Mexicans entering this country were referred to as “rapists and thugs.” African Americans were told that their lives are so bad that they “have nothing to lose” if they voted for a candidate who talked about erecting a wall to block out other people of color, and changing immigration laws that would banish an entire religion from entering our country.
The ‘blue bubble’ – Those who voted for Mrs. Clinton
So … this happened. And, in our consulting rooms, we are seeing a stark increase in the numbers of individuals, couples, and families reporting overwhelming anxiety, sadness, and a sense of de-realization (“it’s surreal”). At the core of their anxiety is concern for self, family, and friends as well as concern for the country as a whole.
The post-election notions that families would be immediately broken up, parents deported, the Affordable Care Act immediately dismantled, and countries bombed immediately after Election Day did not become realities. However, there is valid reason to be concerned. The Southern Poverty Law Center has noted a significant increase in post-election hate crimes throughout the nation.4
The new South ‘red states’ – those who voted for Mr. Trump
Trump supporters are feeling victorious because their “underdog” candidate ran an unconventional presidential campaign and won. However, some who voted for Mr. Trump will at some point experience anxiety when the excitement of “winning” wears off. Psychoanalyst Justin Frank speaks to this and more in his Nov. 9, 2016, blog in which he concludes: “While we mourn and blame others and ourselves for our American tragedy, Trump voters must eventually look at themselves in the mirror and exclaim, ‘what have we done?’ ”5
In his Oct. 25, 2016, New York Times article, Michael Barbaro summarized the behaviors that will become increasingly of concern to all as Mr. Trump accepts the oath of office:
The intense ambitions and undisciplined behaviors of Mr. Trump have confounded even those close to him.... In interviews, Mr. Trump makes clear just how difficult it is for him to imagine – let alone accept – defeat....
“I never had a failure,” Mr. Trump said in one of the interviews, despite his repeated corporate bankruptcies and business setbacks, “because I always turned a failure into a success.”6
This fundamental inability to accept responsibility and the attempt to distort reality is something that must concern each of us, regardless of our ideological differences.
Distress tolerance as a model for healing
Even before the outcome of the election, we were hearing from patients who did not feel safe and who reported being “terrified” about what our country might become. This is where a focus on processing the pain and decreasing anxiety is necessary. This is not an anxiety we can medicate with anxiolytics or rationalize by telling ourselves and our patients that the best man won “fair and square.” We have each – by this time – experienced patients who are quite shaken by this turn of events.
Although it has not received much press, many consider Mr. Trump’s victory to be, in part, a “white backlash.” Many supporters of Mr. Trump have felt too ashamed to publicly admit their support for a candidate who at least by innuendo incited fear, anger, and violence. This failure has created an anxiety reminiscent of the daytime anxiety experienced by people who survived nighttime lynchings in small Southern towns. The day after the lynching, it was not unusual for African American men, women, and children to wonder if their grocer, banker, postal carrier, or sheriff had donned a white hood the night before and lynched someone in their community.
The question of survival, how to survive the unimaginable, is what most distresses people. They’ve wondered out loud whether they, their family, and friends would be attacked and/or killed by those who now feel emboldened and authorized to act on their latent aggressive impulses. And, our patients’ fears are legitimate because, unfortunately, studies show that verbal aggression is correlated with increased risk of physical violence and even murder.7
In the dialectical behavioral therapy (DBT) construct developed by Marsha M. Linehan, PhD, the goals of distress tolerance are crisis survival, reality acceptance, and then freedom.8
As we apply our skills, we are uniquely positioned to help our patients and their families survive this crisis, accept that this is our president-elect, and ultimately be free from the anxiety created by the behavior that we all witnessed. We can aid in the navigation through this storm.
Acceptance
We’re already on to reality acceptance. The reality that so many African Americans and people of color have been living is now known and experienced by many who had felt immune to being marginalized. They now understand the loss of security that accompanies overwhelming fear of being the object of verbal, emotional, and physical aggression and violence.
Some are coping by entertaining fantasies that this election outcome will be undone, that the Electoral College will not approve our president-elect when it meets on Dec. 19 or that Mr. Trump will be impeached early in this upcoming term. The results of the presidential election are unlikely to be undone, so having more than 2 months between Election Day and the inauguration to work on acceptance will be helpful. The goal here is to accept the past, be hopeful about the future, and be vigilant in the present.
Freedom
Now, on to freedom. Our goal is to have all of our patients, families, colleagues, and communities able to live without fear that our leaders are not able to apply humanitarian principles to keep all of us safe. The next few months are crucial. Americans must speak out and debride the wound that bullying intentionally causes. Just as with a school bully, Mr. Trump’s behavior has to be called what it is, not sugarcoated or normalized.
History is full of critical moments in time in which, even in our fear, we said nothing. Even the most empathic of us watched the bully at school and felt relief that his behavior was not directed toward us. But we must not avert our gaze.
Bill Moyers and Michael Winship compared Mr. Trump to Sen. Joseph McCarthy, whose reign of terror was ended when journalist Edward R. Murrow courageously spoke out in defiance of the senator. At the end of one of his segments on “See It Now,” Mr. Murrow concluded as he signed off:
We will not walk in fear, one of another. We will not be driven by fear into an age of unreason, if we dig deep in our history and our doctrine, and remember that we are not descended from fearful men — not from men who feared to write, to speak, to associate and to defend causes that were, for the moment, unpopular.9
And, so, how do we cope?
Fortunately, we understand bullying. The bully doesn’t take over the entire school and won’t have the power to take over one’s entire life if the behavior is brought out in the open and openly discussed. But bullies need to accept responsibility, which is what Sen. Harry Reid of Nevada and other legislators urged President-elect Trump to do in days immediately following the election.10 They have called on him to discourage the fear, anger, and violence leading up to and following the election. This action on Mr. Trump’s part would promote a vitally needed national healing process.
Ultimately, this is “the land of the free, the home of the brave …” and we will do what we have always done as psychiatrists and mental health professionals who help to heal wounds. Not all of us will participate in social justice initiatives. However, each of us can listen with intense compassion and interest to those with whom we identify politically and to those whose views diverge from our own. This is our most potent tool in a conflict where we don’t understand the motives of unpredictable leaders or their followers. It is only with this skilled listening that a space is created in which each “other” hears the “other.” This is where real healing begins.
The views expressed in this article are solely those of the authors, and are not meant to represent the views of the American Psychiatric Association, Novant Health, Clinical Psychiatry News, or any other organization.
References
1. http://billposters/story/trump-virus-dark-age-unreason
2. http://blackdoctor.org/495036/national-medical-association-statement-on-police-use-of-force
3. http://www.nytimes.com/interactive/2016/01/28/upshot/donald-trump-twitter-insults.html?_r=0
4. https://www.splcenter.org/hatewatch/2016/11/11/over-200-incidents-hateful-harassment-and-intimidation-election-day
5. http://www.obamaonthecouch.com
6. http://www.nytimes.com/2016/10/26/us/politics/donald-trump-interviews.html
7. “The Nature of Prejudice,” (New York: Perseus Books Publishing, 1979).
8. DBT® Skills Training Handouts and Worksheets, Second Edition (New York: The Guilford Press, 2014).
9. http://billmoyers.com/story/trump-virus-dark-age-unreason
10. http://www.reid.senate.gov/press_releases/2016-11-11-reid-statement-on-the-election-of-donald-trump#.WC0iA6IrKgR
Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is the immediate past president of the Washington Psychiatric Society, and associate clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics. Dr. Ifill-Taylor, a child, adolescent, and adult psychiatrist, is in practice as a medical director in Charlotte, N.C. Previously, she was in private practice in the Washington area and worked as a staff psychiatrist for the Department of Veterans Affairs. She is particularly interested in the effect of our social, political, and occupational environment on mental and physical health.
Make HIV testing of adolescents routine
Nearly 2 decades ago, I was a pediatric infectious diseases fellow fielding a call from a community pediatrician seeking advice on patient management. The patient in question was a 15-year-old male with fever, rash, and cervical adenopathy – a good clinical story for Epstein-Barr virus infection. A heterophile antibody test was negative, however, as were EBV titers.
We talked for a couple of minutes about the vagaries of EBV testing, as well as other organisms that could cause a mononucleosis-like illness. “Cytomegalovirus is a possibility, along with toxoplasmosis,” I told him. “I’d also test for HIV.”
There was a moment of silence and little throat-clearing. “I don’t think we need to that,” he finally responded. “I’ve known this boy since he was a baby, and I’m sure HIV’s not an issue. He’s not that kind of kid.”
Bear in mind that we lived in a Midwestern city with low rates of HIV, and I suspect this seasoned pediatrician had never seen a case. I argued (as only an impassioned trainee can) that every kid is the kind that could be at risk for HIV, and testing was ultimately done (and was negative).
A lot has changed in the intervening years. HIV infection, at least in adolescents and adults, can be controlled with a single pill taken once a day. Children infected perinatally can grow up and have (uninfected) children of their own. We have reasonably effective pre- and postexposure prophylaxis.
One thing that hasn’t changed, however, is the reluctance of some of us to test our patients for HIV. So what’s up with that?
It’s not because the virus has gone away. On Oct. 14, 2016, amid little fanfare, the Centers for Disease Control and Prevention released the United States Summary of Notifiable Infectious Diseases and Conditions for 2014. A total of 35,606 cases of HIV infection were diagnosed in the United States and reported to the CDC, and 7,723 were in individuals aged 15-24 years.
It is possible that the number of cases in adolescents is even higher. The CDC estimates as many as 60% of youth with HIV don’t know that they are infected, likely because they’ve never been tested. According to the 2015 Youth Risk Behavior Survey (YRBS), only 10% of United States high school students had ever been tested for HIV, and the number of teens tested has been dropping over time. In 2013, for example, the prevalence of having ever been tested for HIV was 13%.
It’s not because today’s teenagers lack risk factors, including sexual activity and drug use. Just over 30% of the U.S. students surveyed for the YRBS reported sexual intercourse with at least one person in the preceding 3 months, and more than 11% had had four or more lifetime partners. Among sexually active teenagers in the United States, only 57% reported that they or their partner used a condom during last sexual intercourse. Overall, 2% of those surveyed admitted a history of injecting an illegal drug.
It’s not because public health experts haven’t deemed testing a priority. The CDC recommends that everyone aged 13-64 years should get tested at least once. Annual testing is recommended for some individuals, including sexually active gay and bisexual males, those who have had more than one sexual partner since their last HIV test, and those who have another sexually transmitted disease. A 2011 American Academy of Pediatrics policy statement affirms the need for routine testing, calling for all adolescents living in geographic areas with an HIV prevalence greater than 0.1% to be offered routine HIV screening at least once by age 16-18 years. In communities with a lower prevalence, the AAP recommends routine HIV testing for sexually active adolescents as well as those with other risk factors, including substance use. Annual HIV testing is recommended for high-risk teenagers, and whenever testing for other sexually transmitted infections (STIs) is performed.
It’s probably not that most teenagers are being offered HIV tests and they’re declining. In 2008, the emergency department at Le Bonheur Children’s Hospital in Memphis, Tenn., implemented a protocol for routine, opt-out HIV screening for medically stable patients aged 13-18 years (Pediatrics. 2009 Oct;124:1076-84). Of the 2,002 patients approached for screening over an approximately 7-month period, only 267 (13%) opted out and of those, 73 had already been tested.
Yet many of us still are not testing. More recently, investigators in Philadelphia performed a retrospective, cross-sectional study of 1,000 randomly selected 13- to 19-year-old patients attending routine well visits conducted at 29 pediatric primary care practices to assess clinician documentation of sexual history and screening for STIs and HIV (J Pediatr. 2014 Aug;165[2]:343-7). Only 212 visits (21.2%) had a documented sexual history, and only 16 patients were tested for HIV (1.6%). HIV testing was more likely to be performed on older adolescents, those of non-Hispanic black race/ethnicity, and those with nonprivate insurance. Study authors called the results “concerning” and advocated for standardized protocols, documentation templates, and electronic decision support to facilitate improved sexual health assessments and screening.
I suspect we all can do better. I’m not a primary care provider, but I do see adolescents with a variety of complaints. I’m pretty diligent about testing teenagers admitted with unexplained fever, vague constitutional symptoms, and those with symptoms that suggest another STI. I’m less effective at discussing HIV testing with those being treated for a postop wound infection, or a routine community-acquired pneumonia.
December is a good time to reflect on practice and make resolutions for the new year. I resolve to talk to more of my adolescent patients about HIV. Who’s with me?
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville, Ky., and Kosair Children’s Hospital, also in Louisville. Email her at [email protected].
Nearly 2 decades ago, I was a pediatric infectious diseases fellow fielding a call from a community pediatrician seeking advice on patient management. The patient in question was a 15-year-old male with fever, rash, and cervical adenopathy – a good clinical story for Epstein-Barr virus infection. A heterophile antibody test was negative, however, as were EBV titers.
We talked for a couple of minutes about the vagaries of EBV testing, as well as other organisms that could cause a mononucleosis-like illness. “Cytomegalovirus is a possibility, along with toxoplasmosis,” I told him. “I’d also test for HIV.”
There was a moment of silence and little throat-clearing. “I don’t think we need to that,” he finally responded. “I’ve known this boy since he was a baby, and I’m sure HIV’s not an issue. He’s not that kind of kid.”
Bear in mind that we lived in a Midwestern city with low rates of HIV, and I suspect this seasoned pediatrician had never seen a case. I argued (as only an impassioned trainee can) that every kid is the kind that could be at risk for HIV, and testing was ultimately done (and was negative).
A lot has changed in the intervening years. HIV infection, at least in adolescents and adults, can be controlled with a single pill taken once a day. Children infected perinatally can grow up and have (uninfected) children of their own. We have reasonably effective pre- and postexposure prophylaxis.
One thing that hasn’t changed, however, is the reluctance of some of us to test our patients for HIV. So what’s up with that?
It’s not because the virus has gone away. On Oct. 14, 2016, amid little fanfare, the Centers for Disease Control and Prevention released the United States Summary of Notifiable Infectious Diseases and Conditions for 2014. A total of 35,606 cases of HIV infection were diagnosed in the United States and reported to the CDC, and 7,723 were in individuals aged 15-24 years.
It is possible that the number of cases in adolescents is even higher. The CDC estimates as many as 60% of youth with HIV don’t know that they are infected, likely because they’ve never been tested. According to the 2015 Youth Risk Behavior Survey (YRBS), only 10% of United States high school students had ever been tested for HIV, and the number of teens tested has been dropping over time. In 2013, for example, the prevalence of having ever been tested for HIV was 13%.
It’s not because today’s teenagers lack risk factors, including sexual activity and drug use. Just over 30% of the U.S. students surveyed for the YRBS reported sexual intercourse with at least one person in the preceding 3 months, and more than 11% had had four or more lifetime partners. Among sexually active teenagers in the United States, only 57% reported that they or their partner used a condom during last sexual intercourse. Overall, 2% of those surveyed admitted a history of injecting an illegal drug.
It’s not because public health experts haven’t deemed testing a priority. The CDC recommends that everyone aged 13-64 years should get tested at least once. Annual testing is recommended for some individuals, including sexually active gay and bisexual males, those who have had more than one sexual partner since their last HIV test, and those who have another sexually transmitted disease. A 2011 American Academy of Pediatrics policy statement affirms the need for routine testing, calling for all adolescents living in geographic areas with an HIV prevalence greater than 0.1% to be offered routine HIV screening at least once by age 16-18 years. In communities with a lower prevalence, the AAP recommends routine HIV testing for sexually active adolescents as well as those with other risk factors, including substance use. Annual HIV testing is recommended for high-risk teenagers, and whenever testing for other sexually transmitted infections (STIs) is performed.
It’s probably not that most teenagers are being offered HIV tests and they’re declining. In 2008, the emergency department at Le Bonheur Children’s Hospital in Memphis, Tenn., implemented a protocol for routine, opt-out HIV screening for medically stable patients aged 13-18 years (Pediatrics. 2009 Oct;124:1076-84). Of the 2,002 patients approached for screening over an approximately 7-month period, only 267 (13%) opted out and of those, 73 had already been tested.
Yet many of us still are not testing. More recently, investigators in Philadelphia performed a retrospective, cross-sectional study of 1,000 randomly selected 13- to 19-year-old patients attending routine well visits conducted at 29 pediatric primary care practices to assess clinician documentation of sexual history and screening for STIs and HIV (J Pediatr. 2014 Aug;165[2]:343-7). Only 212 visits (21.2%) had a documented sexual history, and only 16 patients were tested for HIV (1.6%). HIV testing was more likely to be performed on older adolescents, those of non-Hispanic black race/ethnicity, and those with nonprivate insurance. Study authors called the results “concerning” and advocated for standardized protocols, documentation templates, and electronic decision support to facilitate improved sexual health assessments and screening.
I suspect we all can do better. I’m not a primary care provider, but I do see adolescents with a variety of complaints. I’m pretty diligent about testing teenagers admitted with unexplained fever, vague constitutional symptoms, and those with symptoms that suggest another STI. I’m less effective at discussing HIV testing with those being treated for a postop wound infection, or a routine community-acquired pneumonia.
December is a good time to reflect on practice and make resolutions for the new year. I resolve to talk to more of my adolescent patients about HIV. Who’s with me?
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville, Ky., and Kosair Children’s Hospital, also in Louisville. Email her at [email protected].
Nearly 2 decades ago, I was a pediatric infectious diseases fellow fielding a call from a community pediatrician seeking advice on patient management. The patient in question was a 15-year-old male with fever, rash, and cervical adenopathy – a good clinical story for Epstein-Barr virus infection. A heterophile antibody test was negative, however, as were EBV titers.
We talked for a couple of minutes about the vagaries of EBV testing, as well as other organisms that could cause a mononucleosis-like illness. “Cytomegalovirus is a possibility, along with toxoplasmosis,” I told him. “I’d also test for HIV.”
There was a moment of silence and little throat-clearing. “I don’t think we need to that,” he finally responded. “I’ve known this boy since he was a baby, and I’m sure HIV’s not an issue. He’s not that kind of kid.”
Bear in mind that we lived in a Midwestern city with low rates of HIV, and I suspect this seasoned pediatrician had never seen a case. I argued (as only an impassioned trainee can) that every kid is the kind that could be at risk for HIV, and testing was ultimately done (and was negative).
A lot has changed in the intervening years. HIV infection, at least in adolescents and adults, can be controlled with a single pill taken once a day. Children infected perinatally can grow up and have (uninfected) children of their own. We have reasonably effective pre- and postexposure prophylaxis.
One thing that hasn’t changed, however, is the reluctance of some of us to test our patients for HIV. So what’s up with that?
It’s not because the virus has gone away. On Oct. 14, 2016, amid little fanfare, the Centers for Disease Control and Prevention released the United States Summary of Notifiable Infectious Diseases and Conditions for 2014. A total of 35,606 cases of HIV infection were diagnosed in the United States and reported to the CDC, and 7,723 were in individuals aged 15-24 years.
It is possible that the number of cases in adolescents is even higher. The CDC estimates as many as 60% of youth with HIV don’t know that they are infected, likely because they’ve never been tested. According to the 2015 Youth Risk Behavior Survey (YRBS), only 10% of United States high school students had ever been tested for HIV, and the number of teens tested has been dropping over time. In 2013, for example, the prevalence of having ever been tested for HIV was 13%.
It’s not because today’s teenagers lack risk factors, including sexual activity and drug use. Just over 30% of the U.S. students surveyed for the YRBS reported sexual intercourse with at least one person in the preceding 3 months, and more than 11% had had four or more lifetime partners. Among sexually active teenagers in the United States, only 57% reported that they or their partner used a condom during last sexual intercourse. Overall, 2% of those surveyed admitted a history of injecting an illegal drug.
It’s not because public health experts haven’t deemed testing a priority. The CDC recommends that everyone aged 13-64 years should get tested at least once. Annual testing is recommended for some individuals, including sexually active gay and bisexual males, those who have had more than one sexual partner since their last HIV test, and those who have another sexually transmitted disease. A 2011 American Academy of Pediatrics policy statement affirms the need for routine testing, calling for all adolescents living in geographic areas with an HIV prevalence greater than 0.1% to be offered routine HIV screening at least once by age 16-18 years. In communities with a lower prevalence, the AAP recommends routine HIV testing for sexually active adolescents as well as those with other risk factors, including substance use. Annual HIV testing is recommended for high-risk teenagers, and whenever testing for other sexually transmitted infections (STIs) is performed.
It’s probably not that most teenagers are being offered HIV tests and they’re declining. In 2008, the emergency department at Le Bonheur Children’s Hospital in Memphis, Tenn., implemented a protocol for routine, opt-out HIV screening for medically stable patients aged 13-18 years (Pediatrics. 2009 Oct;124:1076-84). Of the 2,002 patients approached for screening over an approximately 7-month period, only 267 (13%) opted out and of those, 73 had already been tested.
Yet many of us still are not testing. More recently, investigators in Philadelphia performed a retrospective, cross-sectional study of 1,000 randomly selected 13- to 19-year-old patients attending routine well visits conducted at 29 pediatric primary care practices to assess clinician documentation of sexual history and screening for STIs and HIV (J Pediatr. 2014 Aug;165[2]:343-7). Only 212 visits (21.2%) had a documented sexual history, and only 16 patients were tested for HIV (1.6%). HIV testing was more likely to be performed on older adolescents, those of non-Hispanic black race/ethnicity, and those with nonprivate insurance. Study authors called the results “concerning” and advocated for standardized protocols, documentation templates, and electronic decision support to facilitate improved sexual health assessments and screening.
I suspect we all can do better. I’m not a primary care provider, but I do see adolescents with a variety of complaints. I’m pretty diligent about testing teenagers admitted with unexplained fever, vague constitutional symptoms, and those with symptoms that suggest another STI. I’m less effective at discussing HIV testing with those being treated for a postop wound infection, or a routine community-acquired pneumonia.
December is a good time to reflect on practice and make resolutions for the new year. I resolve to talk to more of my adolescent patients about HIV. Who’s with me?
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville, Ky., and Kosair Children’s Hospital, also in Louisville. Email her at [email protected].
My Fitness Journey
One month into my doctoral program, I was stressed out, anxious, not sleeping well, and gaining weight. I expressed these concerns to my daughter, who is a professional bodybuilder and fitness coach; she offered to help me get healthy and fit while earning my doctorate from Rocky Mountain University of Health Professions in Provo, Utah. Over the next two years, I lost 35 pounds and 12 inches of fat from my belly and became more muscular than ever before! I even decided to participate in my first bodybuilding show, “Debut at 62,” on November 19th in Providence, Rhode Island.
I was honored to be the student commencement speaker and recipient of the Student Service Award for my contributions to the NP profession—but what I’m most proud of is adopting a healthy and fit lifestyle in the midst of the most stressful two years of my life. In fact, I believe learning to cope with extreme stress helped me perform more effectively in my doctoral program. I had more energy and concentration, better sleep, and very few physical complaints.
Certainly, I realize that it can be difficult for us to walk our talk and be role models for our patients. When faced with extreme stress we often “crash and burn.” We gain weight, get depressed, sleep poorly, stop having sex, drink excessively, you name it! We know what we should do but lack the energy, time, and motivation to implement and maintain healthy habits. In order to effectively deal with the stress in our lives, we must practice self-care. This approach may seem counterintuitive, as our natural reaction to stress is usually to abandon healthy habits and resort to eating junk food, drinking alcohol, watching TV, and not exercising. It requires conscious effort, development of new habits (and breaking of old ones!), practice, consistency, and a lot of support to cope with stress in a positive way. Mind control, meditation, and paced breathing are other cognitive-based techniques that can be used to help combat the negative effects of stress and anxiety.
As a result of my experience and transformation, my daughter and I decided to team up to help other NPs and PAs make positive changes in their lives. Under the names Coach Kat and Doctor Mimi, we developed The Secor Initiative—an intensive, one-year, online program for NPs or PAs who are seriously committed to becoming healthy, happy, and fit. Upon completion of the program, participants achieve the esteemed title of “Top NP” or “Top PA,” enabling them to be role models for their peers and patients.
The Secor Initiative helps NPs and PAs gain insight into all the sources of stress in their lives and then go on to learn how to cope with these stressors. Our program includes five (10-week) courses, with topics such as nutrition, exercise, money/wealth, stress management, and advanced women’s health; for more information, visit www.MimiSecor.com and click on The Secor Initiative or check out our Facebook page, Coach Kat and Dr. Mimi.
Let’s step up to the plate and become healthy (and happy) role models for our patients.
One month into my doctoral program, I was stressed out, anxious, not sleeping well, and gaining weight. I expressed these concerns to my daughter, who is a professional bodybuilder and fitness coach; she offered to help me get healthy and fit while earning my doctorate from Rocky Mountain University of Health Professions in Provo, Utah. Over the next two years, I lost 35 pounds and 12 inches of fat from my belly and became more muscular than ever before! I even decided to participate in my first bodybuilding show, “Debut at 62,” on November 19th in Providence, Rhode Island.
I was honored to be the student commencement speaker and recipient of the Student Service Award for my contributions to the NP profession—but what I’m most proud of is adopting a healthy and fit lifestyle in the midst of the most stressful two years of my life. In fact, I believe learning to cope with extreme stress helped me perform more effectively in my doctoral program. I had more energy and concentration, better sleep, and very few physical complaints.
Certainly, I realize that it can be difficult for us to walk our talk and be role models for our patients. When faced with extreme stress we often “crash and burn.” We gain weight, get depressed, sleep poorly, stop having sex, drink excessively, you name it! We know what we should do but lack the energy, time, and motivation to implement and maintain healthy habits. In order to effectively deal with the stress in our lives, we must practice self-care. This approach may seem counterintuitive, as our natural reaction to stress is usually to abandon healthy habits and resort to eating junk food, drinking alcohol, watching TV, and not exercising. It requires conscious effort, development of new habits (and breaking of old ones!), practice, consistency, and a lot of support to cope with stress in a positive way. Mind control, meditation, and paced breathing are other cognitive-based techniques that can be used to help combat the negative effects of stress and anxiety.
As a result of my experience and transformation, my daughter and I decided to team up to help other NPs and PAs make positive changes in their lives. Under the names Coach Kat and Doctor Mimi, we developed The Secor Initiative—an intensive, one-year, online program for NPs or PAs who are seriously committed to becoming healthy, happy, and fit. Upon completion of the program, participants achieve the esteemed title of “Top NP” or “Top PA,” enabling them to be role models for their peers and patients.
The Secor Initiative helps NPs and PAs gain insight into all the sources of stress in their lives and then go on to learn how to cope with these stressors. Our program includes five (10-week) courses, with topics such as nutrition, exercise, money/wealth, stress management, and advanced women’s health; for more information, visit www.MimiSecor.com and click on The Secor Initiative or check out our Facebook page, Coach Kat and Dr. Mimi.
Let’s step up to the plate and become healthy (and happy) role models for our patients.
One month into my doctoral program, I was stressed out, anxious, not sleeping well, and gaining weight. I expressed these concerns to my daughter, who is a professional bodybuilder and fitness coach; she offered to help me get healthy and fit while earning my doctorate from Rocky Mountain University of Health Professions in Provo, Utah. Over the next two years, I lost 35 pounds and 12 inches of fat from my belly and became more muscular than ever before! I even decided to participate in my first bodybuilding show, “Debut at 62,” on November 19th in Providence, Rhode Island.
I was honored to be the student commencement speaker and recipient of the Student Service Award for my contributions to the NP profession—but what I’m most proud of is adopting a healthy and fit lifestyle in the midst of the most stressful two years of my life. In fact, I believe learning to cope with extreme stress helped me perform more effectively in my doctoral program. I had more energy and concentration, better sleep, and very few physical complaints.
Certainly, I realize that it can be difficult for us to walk our talk and be role models for our patients. When faced with extreme stress we often “crash and burn.” We gain weight, get depressed, sleep poorly, stop having sex, drink excessively, you name it! We know what we should do but lack the energy, time, and motivation to implement and maintain healthy habits. In order to effectively deal with the stress in our lives, we must practice self-care. This approach may seem counterintuitive, as our natural reaction to stress is usually to abandon healthy habits and resort to eating junk food, drinking alcohol, watching TV, and not exercising. It requires conscious effort, development of new habits (and breaking of old ones!), practice, consistency, and a lot of support to cope with stress in a positive way. Mind control, meditation, and paced breathing are other cognitive-based techniques that can be used to help combat the negative effects of stress and anxiety.
As a result of my experience and transformation, my daughter and I decided to team up to help other NPs and PAs make positive changes in their lives. Under the names Coach Kat and Doctor Mimi, we developed The Secor Initiative—an intensive, one-year, online program for NPs or PAs who are seriously committed to becoming healthy, happy, and fit. Upon completion of the program, participants achieve the esteemed title of “Top NP” or “Top PA,” enabling them to be role models for their peers and patients.
The Secor Initiative helps NPs and PAs gain insight into all the sources of stress in their lives and then go on to learn how to cope with these stressors. Our program includes five (10-week) courses, with topics such as nutrition, exercise, money/wealth, stress management, and advanced women’s health; for more information, visit www.MimiSecor.com and click on The Secor Initiative or check out our Facebook page, Coach Kat and Dr. Mimi.
Let’s step up to the plate and become healthy (and happy) role models for our patients.
Threats in school: Is there a role for you?
Do you remember that kid in your class threatening to beat up a peer (or maybe you) after school? Mean children are not unique to current times. But actual threat to life while in school is a more recent problem, mainly due to the availability of firearms in American homes. Although rates of victimization have actually dropped 86% from 1992 to 2014, stories about school shootings are instantly broadcast across the country, making everyone feel that it could happen to them. Such public awareness also models threatening violence as a potent attention getter.
Often the threatening child lacks not only the skills to manage the frustrating situation, but also the language ability to choose less incendiary words. Saying, “I don’t think the way you handled that was fair to me,” might always be difficult, but is certainly impossible under the high emotions of the moment. Instead, “I’m going to kill you” pops out of their mouths. As for asking for help, school-aged children can only apologize or confess to being unsure a limited number of times before their need to save face takes precedence. This is especially true if they are confronted and humiliated in front of their peers.
Children who have oppositional or aggressive behavior diagnoses are by definition already in a pattern of reacting with hostility when demands are placed on them. In some cases, these negative reactions successfully get their parent(s) to back off the demand, resulting in what is called the “coercive cycle of interaction,” a prodrome to conduct disorder. Then, when a teacher issues a command, their reflexive response is more likely to be a defiant or aggressive one.
When threatening behavior is met by the supervising adults with confrontation, things may further accelerate, again especially in front of peers before whom the student does not want to look weak. Instead, a methodical approach to threat assessment in schools has been shown to be more effective. The main features of effective threat assessment involve identifying student threats, determining their seriousness, and developing intervention plans that both protect potential victims and address the underlying problem or conflict that sparked the threat.
A model program, Virginia Model for Student Threat Assessment by Dewey G. Cornell, PhD, of the University of Virginia, has been shown to help sort out transient (70%) from substantive (30%) threats and resulted in fewer long-term suspensions or expulsions and no cases in which the threats were carried out. (Send a copy to your local school superintendent.) While children receiving special education made three times more threats and more severe threats, they did not require more suspensions. With this threat assessment program, the number of disciplinary office referrals for these students declined by about 55% for the rest of that school year. Students in schools using this method reported less bullying, a greater willingness to seek help for bullying and threats, and more positive perceptions of the school climate as having fairer discipline and less aggression. Resulting plans to help the students involved in threats included modifications to special education plans, academic and behavioral support services, and referrals to mental health services. All these interventions are intended to address gaps in skills. In addition, ways to give even struggling students a meaningful connection to their school – for example, through sports, art, music, clubs, or volunteering – are essential components of both prevention and management.
There are several ways you, as a pediatrician, may be involved in the issue of threats at school. If one of your patients has been accused of threatening behavior, your knowledge of the child and family puts you in the best position to sort out the seriousness of the threat and appropriate next steps. Recently, one of my patients with mild autism was suspended for threatening to “kill the teacher.” He had never been aggressive at home or at school. This 8-year-old usually has a one-on-one aide, but the aide had been pulled to help other students. After an unannounced fire drill, the child called the teacher “evil” and was given his “third strike” for behavior, resulting in him making this threat.
Threat assessment in schools needs to follow the method of functional behavioral assessment, which should actually be standard for all school behavior problems. The method should consider the A (antecedent), B (behavior), C (consequence), and G (gaps) of the behavior. The antecedent here included the “setting” event of the fire drill. The behavior (sometimes also the belief) was the child’s negative reaction to the teacher (who had failed to protect him from being frightened). The consequence was a punishment (third strike) that the child felt was unfair. The gaps in skills included the facts that this is an anxious child who depends on support and routine because of his autism and who is also hypersensitive to loud noise such as a fire drill. In this case, I was able to explain these things to the school, but, in any case, you can, and should, request that the school perform a functional behavioral assessment when dealing with threats.
When you have a child with learning or emotional problems under your care, you need to include asking if they feel safe at school and if anything scary or bad has happened to them there. The parents may need to be directed to meet with school personnel about threats or fears the child reports. School violence prevention programs often include education of the children to be alert for and report threatening peers. This gives students an active role, but also may cause increased anxiety. Parents may need your support in requesting exemption from the school’s “violence prevention training” for anxious children. Anxious parents also may need extra coaching to avoid exposing their children to discussions about school threats.
In caring for all school-aged children (girls are as likely to be involved in school violence as boys), I ask about whether their teachers are nice or mean. I also ask if they have been bullied at school or have bullied others. I also sometimes ask struggling children, “If you had the choice, would you rather go to school or stay home?” The normal, almost universal preference is to go to school. School is the child’s job and social home, and, even when the work is hard, the need for mastery drives children to keep trying. Children preferring to be home are likely in pain and deserve careful assessment of their skills, their emotions, and the school and family environments.
While the percentage of students who reported being afraid of attack or harm at school decreased from 12% in 1995 to 3% in 2013, twice as many African American and Hispanic students feared being attacked than white students. It is clear that feeling anxious interferes with learning. Actual past experience with violence further lowers the threshold for feeling upset. The risk to learning of being fearful at school for children in stressed neighborhoods is multiplied by violence they may experience around them at home, causing even greater impact. Even when actual violence is rare, the media have put all kids and parents on edge about whether they are safe at school. This is a tragedy for everyone involved.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Do you remember that kid in your class threatening to beat up a peer (or maybe you) after school? Mean children are not unique to current times. But actual threat to life while in school is a more recent problem, mainly due to the availability of firearms in American homes. Although rates of victimization have actually dropped 86% from 1992 to 2014, stories about school shootings are instantly broadcast across the country, making everyone feel that it could happen to them. Such public awareness also models threatening violence as a potent attention getter.
Often the threatening child lacks not only the skills to manage the frustrating situation, but also the language ability to choose less incendiary words. Saying, “I don’t think the way you handled that was fair to me,” might always be difficult, but is certainly impossible under the high emotions of the moment. Instead, “I’m going to kill you” pops out of their mouths. As for asking for help, school-aged children can only apologize or confess to being unsure a limited number of times before their need to save face takes precedence. This is especially true if they are confronted and humiliated in front of their peers.
Children who have oppositional or aggressive behavior diagnoses are by definition already in a pattern of reacting with hostility when demands are placed on them. In some cases, these negative reactions successfully get their parent(s) to back off the demand, resulting in what is called the “coercive cycle of interaction,” a prodrome to conduct disorder. Then, when a teacher issues a command, their reflexive response is more likely to be a defiant or aggressive one.
When threatening behavior is met by the supervising adults with confrontation, things may further accelerate, again especially in front of peers before whom the student does not want to look weak. Instead, a methodical approach to threat assessment in schools has been shown to be more effective. The main features of effective threat assessment involve identifying student threats, determining their seriousness, and developing intervention plans that both protect potential victims and address the underlying problem or conflict that sparked the threat.
A model program, Virginia Model for Student Threat Assessment by Dewey G. Cornell, PhD, of the University of Virginia, has been shown to help sort out transient (70%) from substantive (30%) threats and resulted in fewer long-term suspensions or expulsions and no cases in which the threats were carried out. (Send a copy to your local school superintendent.) While children receiving special education made three times more threats and more severe threats, they did not require more suspensions. With this threat assessment program, the number of disciplinary office referrals for these students declined by about 55% for the rest of that school year. Students in schools using this method reported less bullying, a greater willingness to seek help for bullying and threats, and more positive perceptions of the school climate as having fairer discipline and less aggression. Resulting plans to help the students involved in threats included modifications to special education plans, academic and behavioral support services, and referrals to mental health services. All these interventions are intended to address gaps in skills. In addition, ways to give even struggling students a meaningful connection to their school – for example, through sports, art, music, clubs, or volunteering – are essential components of both prevention and management.
There are several ways you, as a pediatrician, may be involved in the issue of threats at school. If one of your patients has been accused of threatening behavior, your knowledge of the child and family puts you in the best position to sort out the seriousness of the threat and appropriate next steps. Recently, one of my patients with mild autism was suspended for threatening to “kill the teacher.” He had never been aggressive at home or at school. This 8-year-old usually has a one-on-one aide, but the aide had been pulled to help other students. After an unannounced fire drill, the child called the teacher “evil” and was given his “third strike” for behavior, resulting in him making this threat.
Threat assessment in schools needs to follow the method of functional behavioral assessment, which should actually be standard for all school behavior problems. The method should consider the A (antecedent), B (behavior), C (consequence), and G (gaps) of the behavior. The antecedent here included the “setting” event of the fire drill. The behavior (sometimes also the belief) was the child’s negative reaction to the teacher (who had failed to protect him from being frightened). The consequence was a punishment (third strike) that the child felt was unfair. The gaps in skills included the facts that this is an anxious child who depends on support and routine because of his autism and who is also hypersensitive to loud noise such as a fire drill. In this case, I was able to explain these things to the school, but, in any case, you can, and should, request that the school perform a functional behavioral assessment when dealing with threats.
When you have a child with learning or emotional problems under your care, you need to include asking if they feel safe at school and if anything scary or bad has happened to them there. The parents may need to be directed to meet with school personnel about threats or fears the child reports. School violence prevention programs often include education of the children to be alert for and report threatening peers. This gives students an active role, but also may cause increased anxiety. Parents may need your support in requesting exemption from the school’s “violence prevention training” for anxious children. Anxious parents also may need extra coaching to avoid exposing their children to discussions about school threats.
In caring for all school-aged children (girls are as likely to be involved in school violence as boys), I ask about whether their teachers are nice or mean. I also ask if they have been bullied at school or have bullied others. I also sometimes ask struggling children, “If you had the choice, would you rather go to school or stay home?” The normal, almost universal preference is to go to school. School is the child’s job and social home, and, even when the work is hard, the need for mastery drives children to keep trying. Children preferring to be home are likely in pain and deserve careful assessment of their skills, their emotions, and the school and family environments.
While the percentage of students who reported being afraid of attack or harm at school decreased from 12% in 1995 to 3% in 2013, twice as many African American and Hispanic students feared being attacked than white students. It is clear that feeling anxious interferes with learning. Actual past experience with violence further lowers the threshold for feeling upset. The risk to learning of being fearful at school for children in stressed neighborhoods is multiplied by violence they may experience around them at home, causing even greater impact. Even when actual violence is rare, the media have put all kids and parents on edge about whether they are safe at school. This is a tragedy for everyone involved.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Do you remember that kid in your class threatening to beat up a peer (or maybe you) after school? Mean children are not unique to current times. But actual threat to life while in school is a more recent problem, mainly due to the availability of firearms in American homes. Although rates of victimization have actually dropped 86% from 1992 to 2014, stories about school shootings are instantly broadcast across the country, making everyone feel that it could happen to them. Such public awareness also models threatening violence as a potent attention getter.
Often the threatening child lacks not only the skills to manage the frustrating situation, but also the language ability to choose less incendiary words. Saying, “I don’t think the way you handled that was fair to me,” might always be difficult, but is certainly impossible under the high emotions of the moment. Instead, “I’m going to kill you” pops out of their mouths. As for asking for help, school-aged children can only apologize or confess to being unsure a limited number of times before their need to save face takes precedence. This is especially true if they are confronted and humiliated in front of their peers.
Children who have oppositional or aggressive behavior diagnoses are by definition already in a pattern of reacting with hostility when demands are placed on them. In some cases, these negative reactions successfully get their parent(s) to back off the demand, resulting in what is called the “coercive cycle of interaction,” a prodrome to conduct disorder. Then, when a teacher issues a command, their reflexive response is more likely to be a defiant or aggressive one.
When threatening behavior is met by the supervising adults with confrontation, things may further accelerate, again especially in front of peers before whom the student does not want to look weak. Instead, a methodical approach to threat assessment in schools has been shown to be more effective. The main features of effective threat assessment involve identifying student threats, determining their seriousness, and developing intervention plans that both protect potential victims and address the underlying problem or conflict that sparked the threat.
A model program, Virginia Model for Student Threat Assessment by Dewey G. Cornell, PhD, of the University of Virginia, has been shown to help sort out transient (70%) from substantive (30%) threats and resulted in fewer long-term suspensions or expulsions and no cases in which the threats were carried out. (Send a copy to your local school superintendent.) While children receiving special education made three times more threats and more severe threats, they did not require more suspensions. With this threat assessment program, the number of disciplinary office referrals for these students declined by about 55% for the rest of that school year. Students in schools using this method reported less bullying, a greater willingness to seek help for bullying and threats, and more positive perceptions of the school climate as having fairer discipline and less aggression. Resulting plans to help the students involved in threats included modifications to special education plans, academic and behavioral support services, and referrals to mental health services. All these interventions are intended to address gaps in skills. In addition, ways to give even struggling students a meaningful connection to their school – for example, through sports, art, music, clubs, or volunteering – are essential components of both prevention and management.
There are several ways you, as a pediatrician, may be involved in the issue of threats at school. If one of your patients has been accused of threatening behavior, your knowledge of the child and family puts you in the best position to sort out the seriousness of the threat and appropriate next steps. Recently, one of my patients with mild autism was suspended for threatening to “kill the teacher.” He had never been aggressive at home or at school. This 8-year-old usually has a one-on-one aide, but the aide had been pulled to help other students. After an unannounced fire drill, the child called the teacher “evil” and was given his “third strike” for behavior, resulting in him making this threat.
Threat assessment in schools needs to follow the method of functional behavioral assessment, which should actually be standard for all school behavior problems. The method should consider the A (antecedent), B (behavior), C (consequence), and G (gaps) of the behavior. The antecedent here included the “setting” event of the fire drill. The behavior (sometimes also the belief) was the child’s negative reaction to the teacher (who had failed to protect him from being frightened). The consequence was a punishment (third strike) that the child felt was unfair. The gaps in skills included the facts that this is an anxious child who depends on support and routine because of his autism and who is also hypersensitive to loud noise such as a fire drill. In this case, I was able to explain these things to the school, but, in any case, you can, and should, request that the school perform a functional behavioral assessment when dealing with threats.
When you have a child with learning or emotional problems under your care, you need to include asking if they feel safe at school and if anything scary or bad has happened to them there. The parents may need to be directed to meet with school personnel about threats or fears the child reports. School violence prevention programs often include education of the children to be alert for and report threatening peers. This gives students an active role, but also may cause increased anxiety. Parents may need your support in requesting exemption from the school’s “violence prevention training” for anxious children. Anxious parents also may need extra coaching to avoid exposing their children to discussions about school threats.
In caring for all school-aged children (girls are as likely to be involved in school violence as boys), I ask about whether their teachers are nice or mean. I also ask if they have been bullied at school or have bullied others. I also sometimes ask struggling children, “If you had the choice, would you rather go to school or stay home?” The normal, almost universal preference is to go to school. School is the child’s job and social home, and, even when the work is hard, the need for mastery drives children to keep trying. Children preferring to be home are likely in pain and deserve careful assessment of their skills, their emotions, and the school and family environments.
While the percentage of students who reported being afraid of attack or harm at school decreased from 12% in 1995 to 3% in 2013, twice as many African American and Hispanic students feared being attacked than white students. It is clear that feeling anxious interferes with learning. Actual past experience with violence further lowers the threshold for feeling upset. The risk to learning of being fearful at school for children in stressed neighborhoods is multiplied by violence they may experience around them at home, causing even greater impact. Even when actual violence is rare, the media have put all kids and parents on edge about whether they are safe at school. This is a tragedy for everyone involved.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Fear and hope: Helping LGBT youth cope with the 2016 election results
The day after the election, Time magazine reported an increased call volume to the Trevor Project, an organization that provides suicide counseling for LGBT youth.1 A colleague of mine who works closely with the Trevor Project told me that this was the second-highest call volume the organization has received since its inception.
Regardless of your political affiliation, we all can agree that this year’s election was divisive. Many minority groups, including the LGBT community, felt singled out. Although many of us have seen contentious elections in our lifetimes, teenagers, especially LGBT youth, are sensitive to this divisiveness.
Many LGBT youth who called the Trevor Project had expressed fear about the future. Whenever someone becomes suicidal, they have an overwhelming sense of hopelessness.2 Many perceive that the upcoming administration may be hostile to the LGBT community, and because many fear that this new administration may undo all the progress made in LGBT rights in the last 8 years, they have little hope for the future. Numerous reports of increased hate-crime incidents since the start of the election season last year may have exacerbated this feeling of hopelessness.3 This hopelessness may cause many to feel that the best way out is through suicide. Others feel that their sexual orientation or gender identity may be an additional burden to their family during this new era, and so to relieve them of this burden, they consider ending their own lives.4
For adults who have seen many administrations come and go, this may seem like hyperbole. But we have the advantage of living through various elections and administrations, knowing that they were not as catastrophic as others claimed. However, for many LGBT teens or young adults, this is probably their first election after reaching adolescence since Obama was elected in 2008. The Obama administration has been friendly to the LGBT community,5 and for LGBT youth, the upcoming Trump administration may be a substantial departure from this friendliness. In addition, people across the political spectrum have stoked fears among LGBT youth that the new administration will be devastating for the LGBT community. Adolescents, compared with adults, respond more strongly to the limbic system of the brain – the part of the brain involved in emotional processing, which includes fear.6 This fear will override any attempt by the prefrontal cortex – the part of the brain involved in cognitive processing6 – to put the results of this election within context and within perspective. In other words, it is easier for the adolescent brain to become much more despondent over a disappointing outcome.
What can providers do for LGBT youth who feel distressed over the outcome of the election? The approach is twofold. First, address the emotions emanating from the limbic system. Once this influence is dampened, engage the prefrontal cortex to process the emotions and address these fears in a more constructive way.
For LGBT youth who are actively suicidal, providers should first determine the risk for suicide (for example, determine the level of family support, access to lethal means of suicide, etc.) Then, depending on the risk, create a suicide safety plan that will help the teen or young adult cope with the distress. For more information on how to address suicidality among LGBT youth, please see my previous column (“It does get better... with your help: Preventing suicide,” October 2016, page 30).
Recognize and validate the fears of LGBT youth. Do not dismiss their fears as an overreaction. Because of the adolescent brain’s responsiveness to the limbic system, their fears and emotions are much more intense than are those of adults. Allow them to express how worried they are about the future. Remind them that you are their advocate and that your goal is to keep them safe. Remind your LGBT patients that people who have advocated for them did not disappear overnight because of the election. Some parents of my LGBT patients have pointed out that many LGBT youth feel safer when a nonfamily member advocates for them; therefore, it is essential to remind your LGBT patients about your role as their physician and their advocate.
Another way to support your LGBT patients during this stressful time is to help create a safe environment for them, especially at school. There are some concerns about an increase in antigay and antitrans harassment and bullying since the election.7 Schools are doing their best to respond appropriately to these incidents.8 Fortunately, many schools are responsive to physicians’ recommendations for preventing and addressing school bullying.9 For more information on how providers can address bullying of LGBT youth in school, please refer to my column on bullying (“Bullying,” May 2016, p.1).
Once you reduce the responsiveness of the adolescent brain to the limbic system, you then can focus on the prefrontal cortex to help adolescents engage and cope with their distress. Have them recall from their civics classes that the United States government has checks and balances and that one person does not have unilateral power. Remind the adolescent that administrations and governments do not last forever and that there is an opportunity to change administrations every 4 years.
One of the most powerful ways to engage the prefrontal cortex of the distressed adolescent is to provide the individual with opportunities to be an active member of the community. They can volunteer in many organizations that share their values and beliefs. These organizations do not need to be political, but they should provide some service to the community. This will remind the adolescents that they can have an impact on their own lives and in the lives of others. Volunteering in these organizations will give them a sense of purpose and create a stronger connection to their communities10 – both are antidotes to the intense feeling of despair and hopelessness.
The fear and concerns that LGBT youth have over the election results are intense and deserve attention. Their neurobiology and lack of experience make these fears much more powerful. Providers, parents, and advocates have the responsibility to address these fears, remind LGBT youth that they are their advocates, and remind LGBT youth of the ability to influence the outcomes of their own lives. Providing skills to cope with disappointing outcomes also will prepare LGBT youth for the challenges of adulthood and for the many elections to come.
Resources
AAP: Talking to your children about the election
HealthyChildren.org: How to support your child’s resilience in a time of crisis
Suicide Prevention Lifeline: Patient safety plan template
References
1. “Donald Trump Win Causes Spike in Crisis Support Line Calls,” Time magazine, Nov. 9, 2016.
2. Int Rev Psychiatry. 1992;4(2):177-84.
3. “U.S. Hate Crimes Surge 6%, Fueled by Attacks on Muslims,” the New York Times, Nov. 14, 2016.
4. Arch Suicide Res. 2015;19(3):385-400.
5. “The president of the United States shifted the mainstream in one interview,” Newsweek, May 13, 2012.
6. Neuropsychiatric Disease and Treatment. 2013;9:449-61.
7. “This is Trump’s America: LGBT community fears surge in hate crimes following reports of homophobic attacks,” Salon magazine, Nov. 13, 2016.
8. “School officials grapple with bullying, harassment after election,” Lansing State Journal, Nov. 13, 2016.
9. “Roles for pediatricians in bullying prevention and intervention,” StopBullying.gov, 2016.
10. Adv Psych Treatment. 2014;20(3):217-24.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh. Email him at [email protected].
The day after the election, Time magazine reported an increased call volume to the Trevor Project, an organization that provides suicide counseling for LGBT youth.1 A colleague of mine who works closely with the Trevor Project told me that this was the second-highest call volume the organization has received since its inception.
Regardless of your political affiliation, we all can agree that this year’s election was divisive. Many minority groups, including the LGBT community, felt singled out. Although many of us have seen contentious elections in our lifetimes, teenagers, especially LGBT youth, are sensitive to this divisiveness.
Many LGBT youth who called the Trevor Project had expressed fear about the future. Whenever someone becomes suicidal, they have an overwhelming sense of hopelessness.2 Many perceive that the upcoming administration may be hostile to the LGBT community, and because many fear that this new administration may undo all the progress made in LGBT rights in the last 8 years, they have little hope for the future. Numerous reports of increased hate-crime incidents since the start of the election season last year may have exacerbated this feeling of hopelessness.3 This hopelessness may cause many to feel that the best way out is through suicide. Others feel that their sexual orientation or gender identity may be an additional burden to their family during this new era, and so to relieve them of this burden, they consider ending their own lives.4
For adults who have seen many administrations come and go, this may seem like hyperbole. But we have the advantage of living through various elections and administrations, knowing that they were not as catastrophic as others claimed. However, for many LGBT teens or young adults, this is probably their first election after reaching adolescence since Obama was elected in 2008. The Obama administration has been friendly to the LGBT community,5 and for LGBT youth, the upcoming Trump administration may be a substantial departure from this friendliness. In addition, people across the political spectrum have stoked fears among LGBT youth that the new administration will be devastating for the LGBT community. Adolescents, compared with adults, respond more strongly to the limbic system of the brain – the part of the brain involved in emotional processing, which includes fear.6 This fear will override any attempt by the prefrontal cortex – the part of the brain involved in cognitive processing6 – to put the results of this election within context and within perspective. In other words, it is easier for the adolescent brain to become much more despondent over a disappointing outcome.
What can providers do for LGBT youth who feel distressed over the outcome of the election? The approach is twofold. First, address the emotions emanating from the limbic system. Once this influence is dampened, engage the prefrontal cortex to process the emotions and address these fears in a more constructive way.
For LGBT youth who are actively suicidal, providers should first determine the risk for suicide (for example, determine the level of family support, access to lethal means of suicide, etc.) Then, depending on the risk, create a suicide safety plan that will help the teen or young adult cope with the distress. For more information on how to address suicidality among LGBT youth, please see my previous column (“It does get better... with your help: Preventing suicide,” October 2016, page 30).
Recognize and validate the fears of LGBT youth. Do not dismiss their fears as an overreaction. Because of the adolescent brain’s responsiveness to the limbic system, their fears and emotions are much more intense than are those of adults. Allow them to express how worried they are about the future. Remind them that you are their advocate and that your goal is to keep them safe. Remind your LGBT patients that people who have advocated for them did not disappear overnight because of the election. Some parents of my LGBT patients have pointed out that many LGBT youth feel safer when a nonfamily member advocates for them; therefore, it is essential to remind your LGBT patients about your role as their physician and their advocate.
Another way to support your LGBT patients during this stressful time is to help create a safe environment for them, especially at school. There are some concerns about an increase in antigay and antitrans harassment and bullying since the election.7 Schools are doing their best to respond appropriately to these incidents.8 Fortunately, many schools are responsive to physicians’ recommendations for preventing and addressing school bullying.9 For more information on how providers can address bullying of LGBT youth in school, please refer to my column on bullying (“Bullying,” May 2016, p.1).
Once you reduce the responsiveness of the adolescent brain to the limbic system, you then can focus on the prefrontal cortex to help adolescents engage and cope with their distress. Have them recall from their civics classes that the United States government has checks and balances and that one person does not have unilateral power. Remind the adolescent that administrations and governments do not last forever and that there is an opportunity to change administrations every 4 years.
One of the most powerful ways to engage the prefrontal cortex of the distressed adolescent is to provide the individual with opportunities to be an active member of the community. They can volunteer in many organizations that share their values and beliefs. These organizations do not need to be political, but they should provide some service to the community. This will remind the adolescents that they can have an impact on their own lives and in the lives of others. Volunteering in these organizations will give them a sense of purpose and create a stronger connection to their communities10 – both are antidotes to the intense feeling of despair and hopelessness.
The fear and concerns that LGBT youth have over the election results are intense and deserve attention. Their neurobiology and lack of experience make these fears much more powerful. Providers, parents, and advocates have the responsibility to address these fears, remind LGBT youth that they are their advocates, and remind LGBT youth of the ability to influence the outcomes of their own lives. Providing skills to cope with disappointing outcomes also will prepare LGBT youth for the challenges of adulthood and for the many elections to come.
Resources
AAP: Talking to your children about the election
HealthyChildren.org: How to support your child’s resilience in a time of crisis
Suicide Prevention Lifeline: Patient safety plan template
References
1. “Donald Trump Win Causes Spike in Crisis Support Line Calls,” Time magazine, Nov. 9, 2016.
2. Int Rev Psychiatry. 1992;4(2):177-84.
3. “U.S. Hate Crimes Surge 6%, Fueled by Attacks on Muslims,” the New York Times, Nov. 14, 2016.
4. Arch Suicide Res. 2015;19(3):385-400.
5. “The president of the United States shifted the mainstream in one interview,” Newsweek, May 13, 2012.
6. Neuropsychiatric Disease and Treatment. 2013;9:449-61.
7. “This is Trump’s America: LGBT community fears surge in hate crimes following reports of homophobic attacks,” Salon magazine, Nov. 13, 2016.
8. “School officials grapple with bullying, harassment after election,” Lansing State Journal, Nov. 13, 2016.
9. “Roles for pediatricians in bullying prevention and intervention,” StopBullying.gov, 2016.
10. Adv Psych Treatment. 2014;20(3):217-24.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh. Email him at [email protected].
The day after the election, Time magazine reported an increased call volume to the Trevor Project, an organization that provides suicide counseling for LGBT youth.1 A colleague of mine who works closely with the Trevor Project told me that this was the second-highest call volume the organization has received since its inception.
Regardless of your political affiliation, we all can agree that this year’s election was divisive. Many minority groups, including the LGBT community, felt singled out. Although many of us have seen contentious elections in our lifetimes, teenagers, especially LGBT youth, are sensitive to this divisiveness.
Many LGBT youth who called the Trevor Project had expressed fear about the future. Whenever someone becomes suicidal, they have an overwhelming sense of hopelessness.2 Many perceive that the upcoming administration may be hostile to the LGBT community, and because many fear that this new administration may undo all the progress made in LGBT rights in the last 8 years, they have little hope for the future. Numerous reports of increased hate-crime incidents since the start of the election season last year may have exacerbated this feeling of hopelessness.3 This hopelessness may cause many to feel that the best way out is through suicide. Others feel that their sexual orientation or gender identity may be an additional burden to their family during this new era, and so to relieve them of this burden, they consider ending their own lives.4
For adults who have seen many administrations come and go, this may seem like hyperbole. But we have the advantage of living through various elections and administrations, knowing that they were not as catastrophic as others claimed. However, for many LGBT teens or young adults, this is probably their first election after reaching adolescence since Obama was elected in 2008. The Obama administration has been friendly to the LGBT community,5 and for LGBT youth, the upcoming Trump administration may be a substantial departure from this friendliness. In addition, people across the political spectrum have stoked fears among LGBT youth that the new administration will be devastating for the LGBT community. Adolescents, compared with adults, respond more strongly to the limbic system of the brain – the part of the brain involved in emotional processing, which includes fear.6 This fear will override any attempt by the prefrontal cortex – the part of the brain involved in cognitive processing6 – to put the results of this election within context and within perspective. In other words, it is easier for the adolescent brain to become much more despondent over a disappointing outcome.
What can providers do for LGBT youth who feel distressed over the outcome of the election? The approach is twofold. First, address the emotions emanating from the limbic system. Once this influence is dampened, engage the prefrontal cortex to process the emotions and address these fears in a more constructive way.
For LGBT youth who are actively suicidal, providers should first determine the risk for suicide (for example, determine the level of family support, access to lethal means of suicide, etc.) Then, depending on the risk, create a suicide safety plan that will help the teen or young adult cope with the distress. For more information on how to address suicidality among LGBT youth, please see my previous column (“It does get better... with your help: Preventing suicide,” October 2016, page 30).
Recognize and validate the fears of LGBT youth. Do not dismiss their fears as an overreaction. Because of the adolescent brain’s responsiveness to the limbic system, their fears and emotions are much more intense than are those of adults. Allow them to express how worried they are about the future. Remind them that you are their advocate and that your goal is to keep them safe. Remind your LGBT patients that people who have advocated for them did not disappear overnight because of the election. Some parents of my LGBT patients have pointed out that many LGBT youth feel safer when a nonfamily member advocates for them; therefore, it is essential to remind your LGBT patients about your role as their physician and their advocate.
Another way to support your LGBT patients during this stressful time is to help create a safe environment for them, especially at school. There are some concerns about an increase in antigay and antitrans harassment and bullying since the election.7 Schools are doing their best to respond appropriately to these incidents.8 Fortunately, many schools are responsive to physicians’ recommendations for preventing and addressing school bullying.9 For more information on how providers can address bullying of LGBT youth in school, please refer to my column on bullying (“Bullying,” May 2016, p.1).
Once you reduce the responsiveness of the adolescent brain to the limbic system, you then can focus on the prefrontal cortex to help adolescents engage and cope with their distress. Have them recall from their civics classes that the United States government has checks and balances and that one person does not have unilateral power. Remind the adolescent that administrations and governments do not last forever and that there is an opportunity to change administrations every 4 years.
One of the most powerful ways to engage the prefrontal cortex of the distressed adolescent is to provide the individual with opportunities to be an active member of the community. They can volunteer in many organizations that share their values and beliefs. These organizations do not need to be political, but they should provide some service to the community. This will remind the adolescents that they can have an impact on their own lives and in the lives of others. Volunteering in these organizations will give them a sense of purpose and create a stronger connection to their communities10 – both are antidotes to the intense feeling of despair and hopelessness.
The fear and concerns that LGBT youth have over the election results are intense and deserve attention. Their neurobiology and lack of experience make these fears much more powerful. Providers, parents, and advocates have the responsibility to address these fears, remind LGBT youth that they are their advocates, and remind LGBT youth of the ability to influence the outcomes of their own lives. Providing skills to cope with disappointing outcomes also will prepare LGBT youth for the challenges of adulthood and for the many elections to come.
Resources
AAP: Talking to your children about the election
HealthyChildren.org: How to support your child’s resilience in a time of crisis
Suicide Prevention Lifeline: Patient safety plan template
References
1. “Donald Trump Win Causes Spike in Crisis Support Line Calls,” Time magazine, Nov. 9, 2016.
2. Int Rev Psychiatry. 1992;4(2):177-84.
3. “U.S. Hate Crimes Surge 6%, Fueled by Attacks on Muslims,” the New York Times, Nov. 14, 2016.
4. Arch Suicide Res. 2015;19(3):385-400.
5. “The president of the United States shifted the mainstream in one interview,” Newsweek, May 13, 2012.
6. Neuropsychiatric Disease and Treatment. 2013;9:449-61.
7. “This is Trump’s America: LGBT community fears surge in hate crimes following reports of homophobic attacks,” Salon magazine, Nov. 13, 2016.
8. “School officials grapple with bullying, harassment after election,” Lansing State Journal, Nov. 13, 2016.
9. “Roles for pediatricians in bullying prevention and intervention,” StopBullying.gov, 2016.
10. Adv Psych Treatment. 2014;20(3):217-24.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh. Email him at [email protected].
Postelection anxiety
Introduction
Since the election, many of the psychiatrists and psychologists in our office have reported a wave of anxiety among our patients. These fears have sometimes come from watching television commercials that highlight the faults of the other party or from watching the debates themselves. Children have reported fears of a nuclear war, of being taken away from family, or of being harmed or killed because of racial, religious, immigration, disability, gender, or sexual orientation status. In addition, some children are reporting remarks by peers.
Case summary
Discussion
How can we support our patients and their parents in responding to this surge in anxiety? First, we can reiterate the central importance of family. What the family models in values, behavior, and coping is central to how children respond to stress and winning and losing. Parents who manage their own emotions model how to cope with both victory and defeat, demonstrating appropriate celebration as well as grief and anger. Coping strategies for parents can include reaching out to supports from family and friends, using relaxation strategies, and then planning practical next steps to take.
Parents should reassure their children that they are there to keep their children safe. Modeling self-care and keeping the family routine as stable as possible is a powerful source of this sense of safety. As always, parents should think about what their children are consuming in the way of electronics.
In talking to children, listening is a first step. Help children find the words for what they are feeling. Consider your own words and the rhetoric of the election. Withering scorn of the other side has become increasingly common and not only damages our ability to understand other points of view and resolve conflicts but is also leading to intense anxiety in our children. The extreme nature of some of these words has led some children to believe that complete disaster is imminent should the other side win. Try to avoid using words that intensify fear. Acknowledge the feelings that children have, but provide reassurance of safety and hope.
Using the principles of cognitive-behavioral therapy, a therapist or parent can help a child think through how their thoughts are connected with feelings and behavior. When we are fearful, we often think that the absolute worst is going to happen, or we imagine that we definitely know the future. Sometimes an extreme thought can magnify feelings to the point that constructive behavior is blocked. A therapist might acknowledge feelings, but also help enlarge the child’s perspective. There are many reasons why people voted for or against candidates, and we don’t know everything about them just because of how they chose to vote. Discussing the three branches of government and the system of checks and balances that bring many people together to think over a problem can help a child see that the government is more than just one person. Parents or therapists can talk about protections in the Constitution such as freedom of the press, which allows us to be informed of what is going on. Parents might want to talk about the reality that we are one country, and that the vast majority of people on both sides share many, if not all, values.
Helping a child consider other perspectives isn’t saying that there are no reasons at all for anxiety, but that there are many possibilities for the future, and that a family can think together about what behaviors they want to engage in. There may be specific actions a child or family might want to take to have a voice in how the country moves forward.
Treatment plan for Jane
• Psychotherapy. Continue cognitive-behavioral therapy with a focus on identifying thoughts tied to anxiety that are overgeneralizations or exaggerations. Discuss alternative thoughts with greater perspective.
• Parents. Discuss supporting the child through listening, reassurance of safety, reestablishment of family routine, and family discussion about what actions to take to promote values.
• Health promotion. Discuss using exercise, pleasant activities, mindfulness, and minimizing of screen time as ways to cope with stress.
• Medications. There is no need to use medications for the child’s acute stress response.
Resources
1. Psychological First Aid: Field Operations Manual , 2nd ed. (National Child Traumatic Stress Network, National Center for PTSD, 2006).
2. Cognitive Behavioral Therapy for Anxious Children: Therapist Manual, 3rd edition. (Ardmore, Pa.: Workbook Publishing, 2006).
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Introduction
Since the election, many of the psychiatrists and psychologists in our office have reported a wave of anxiety among our patients. These fears have sometimes come from watching television commercials that highlight the faults of the other party or from watching the debates themselves. Children have reported fears of a nuclear war, of being taken away from family, or of being harmed or killed because of racial, religious, immigration, disability, gender, or sexual orientation status. In addition, some children are reporting remarks by peers.
Case summary
Discussion
How can we support our patients and their parents in responding to this surge in anxiety? First, we can reiterate the central importance of family. What the family models in values, behavior, and coping is central to how children respond to stress and winning and losing. Parents who manage their own emotions model how to cope with both victory and defeat, demonstrating appropriate celebration as well as grief and anger. Coping strategies for parents can include reaching out to supports from family and friends, using relaxation strategies, and then planning practical next steps to take.
Parents should reassure their children that they are there to keep their children safe. Modeling self-care and keeping the family routine as stable as possible is a powerful source of this sense of safety. As always, parents should think about what their children are consuming in the way of electronics.
In talking to children, listening is a first step. Help children find the words for what they are feeling. Consider your own words and the rhetoric of the election. Withering scorn of the other side has become increasingly common and not only damages our ability to understand other points of view and resolve conflicts but is also leading to intense anxiety in our children. The extreme nature of some of these words has led some children to believe that complete disaster is imminent should the other side win. Try to avoid using words that intensify fear. Acknowledge the feelings that children have, but provide reassurance of safety and hope.
Using the principles of cognitive-behavioral therapy, a therapist or parent can help a child think through how their thoughts are connected with feelings and behavior. When we are fearful, we often think that the absolute worst is going to happen, or we imagine that we definitely know the future. Sometimes an extreme thought can magnify feelings to the point that constructive behavior is blocked. A therapist might acknowledge feelings, but also help enlarge the child’s perspective. There are many reasons why people voted for or against candidates, and we don’t know everything about them just because of how they chose to vote. Discussing the three branches of government and the system of checks and balances that bring many people together to think over a problem can help a child see that the government is more than just one person. Parents or therapists can talk about protections in the Constitution such as freedom of the press, which allows us to be informed of what is going on. Parents might want to talk about the reality that we are one country, and that the vast majority of people on both sides share many, if not all, values.
Helping a child consider other perspectives isn’t saying that there are no reasons at all for anxiety, but that there are many possibilities for the future, and that a family can think together about what behaviors they want to engage in. There may be specific actions a child or family might want to take to have a voice in how the country moves forward.
Treatment plan for Jane
• Psychotherapy. Continue cognitive-behavioral therapy with a focus on identifying thoughts tied to anxiety that are overgeneralizations or exaggerations. Discuss alternative thoughts with greater perspective.
• Parents. Discuss supporting the child through listening, reassurance of safety, reestablishment of family routine, and family discussion about what actions to take to promote values.
• Health promotion. Discuss using exercise, pleasant activities, mindfulness, and minimizing of screen time as ways to cope with stress.
• Medications. There is no need to use medications for the child’s acute stress response.
Resources
1. Psychological First Aid: Field Operations Manual , 2nd ed. (National Child Traumatic Stress Network, National Center for PTSD, 2006).
2. Cognitive Behavioral Therapy for Anxious Children: Therapist Manual, 3rd edition. (Ardmore, Pa.: Workbook Publishing, 2006).
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Introduction
Since the election, many of the psychiatrists and psychologists in our office have reported a wave of anxiety among our patients. These fears have sometimes come from watching television commercials that highlight the faults of the other party or from watching the debates themselves. Children have reported fears of a nuclear war, of being taken away from family, or of being harmed or killed because of racial, religious, immigration, disability, gender, or sexual orientation status. In addition, some children are reporting remarks by peers.
Case summary
Discussion
How can we support our patients and their parents in responding to this surge in anxiety? First, we can reiterate the central importance of family. What the family models in values, behavior, and coping is central to how children respond to stress and winning and losing. Parents who manage their own emotions model how to cope with both victory and defeat, demonstrating appropriate celebration as well as grief and anger. Coping strategies for parents can include reaching out to supports from family and friends, using relaxation strategies, and then planning practical next steps to take.
Parents should reassure their children that they are there to keep their children safe. Modeling self-care and keeping the family routine as stable as possible is a powerful source of this sense of safety. As always, parents should think about what their children are consuming in the way of electronics.
In talking to children, listening is a first step. Help children find the words for what they are feeling. Consider your own words and the rhetoric of the election. Withering scorn of the other side has become increasingly common and not only damages our ability to understand other points of view and resolve conflicts but is also leading to intense anxiety in our children. The extreme nature of some of these words has led some children to believe that complete disaster is imminent should the other side win. Try to avoid using words that intensify fear. Acknowledge the feelings that children have, but provide reassurance of safety and hope.
Using the principles of cognitive-behavioral therapy, a therapist or parent can help a child think through how their thoughts are connected with feelings and behavior. When we are fearful, we often think that the absolute worst is going to happen, or we imagine that we definitely know the future. Sometimes an extreme thought can magnify feelings to the point that constructive behavior is blocked. A therapist might acknowledge feelings, but also help enlarge the child’s perspective. There are many reasons why people voted for or against candidates, and we don’t know everything about them just because of how they chose to vote. Discussing the three branches of government and the system of checks and balances that bring many people together to think over a problem can help a child see that the government is more than just one person. Parents or therapists can talk about protections in the Constitution such as freedom of the press, which allows us to be informed of what is going on. Parents might want to talk about the reality that we are one country, and that the vast majority of people on both sides share many, if not all, values.
Helping a child consider other perspectives isn’t saying that there are no reasons at all for anxiety, but that there are many possibilities for the future, and that a family can think together about what behaviors they want to engage in. There may be specific actions a child or family might want to take to have a voice in how the country moves forward.
Treatment plan for Jane
• Psychotherapy. Continue cognitive-behavioral therapy with a focus on identifying thoughts tied to anxiety that are overgeneralizations or exaggerations. Discuss alternative thoughts with greater perspective.
• Parents. Discuss supporting the child through listening, reassurance of safety, reestablishment of family routine, and family discussion about what actions to take to promote values.
• Health promotion. Discuss using exercise, pleasant activities, mindfulness, and minimizing of screen time as ways to cope with stress.
• Medications. There is no need to use medications for the child’s acute stress response.
Resources
1. Psychological First Aid: Field Operations Manual , 2nd ed. (National Child Traumatic Stress Network, National Center for PTSD, 2006).
2. Cognitive Behavioral Therapy for Anxious Children: Therapist Manual, 3rd edition. (Ardmore, Pa.: Workbook Publishing, 2006).
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
The $400 generic
Oren is 11. I often see him around the neighborhood.
The other day I gave his father a lift. “Oren had a rash on his face,” said Ben, slipping into the passenger seat. “The pediatrician said she thought it was eczema, but she gave him an acne medicine.”
I raised my eyebrows, but said nothing.
“How much did it cost?” I asked.
“$400.”
“$400!” I couldn’t quite stifle my shock. “What was in the cream?” I asked.
“Here it is,” he said. “I took a picture of the tube on my phone.”
He showed me a snapshot of a tube of clindamycin/benzoyl peroxide.
Although I try not to meddle in the medical issues of friends, I decided to make a small exception in this case. “Next time someone prescribes an expensive skin cream,” I said, “let me know. Maybe I can help you find a more affordable alternative.”
What skin problem did Oren have? I have no idea. I see his face enough to know that he has no acne at all. Nor would acne go away in 2 days.
On the other hand, if he did have a flare of eczema – I’ve never noticed that on him either – acne medicine would aggravate it, if anything.
Besides those questions, I have another one: Regardless of what she thought the diagnosis was, why on earth did Oren’s pediatrician feel compelled to prescribe a $400 generic? I say “compelled” because she told Ben straight out that the cream was going to cost a lot. But she just had to prescribe it because her experience told her it worked.
What experience did she have, exactly? What else had she tried that didn’t work? And what did she mean by “work”?
Ben’s and Oren’s experience is just a small, unnoticed incident of no general interest. It will spur no magazine exposés, incite no lawsuits, launch no professional or political inquiries.
• Oren’s pediatrician will go on prescribing a hideously priced cream intended to treat who-knows-what. Nobody will suggest to her that she might at least consider doing otherwise.
• Pharmacy benefit managers will not crack down on either pediatrician or cream. They have bigger fish to fry, like biologics that cost $50K per year.
• Health care administrators will take no notice. They will instead think up more creative and onerous disincentives to restrain providers from prescribing anything expensive. Whether they will also figure out how to keep monopolistic generic drug manufacturers from jacking up prices into the stratosphere is something else.
• Medical educators will strengthen their focus on sophisticated science (Genomics! Precision Medicine!), while doing a wholly inadequate job of passing on simple lessons that might help primary clinicians do a better job of managing everyday skin problems. Just yesterday, my colleague and I saw two patients who had been taking doxycycline for years with no clinical benefit, three kids with eczema who had used a succession of antifungal creams for over 4 months, one woman who had been dousing herself repeatedly with permethrin – to no avail – because her mites lived exclusively in her brain and those of her prescribers, and a partridge with alopecia in a pear tree. (OK, not the last one). All that in just 1 day!
• Simple common sense will stay elusive. Most rashes are really not rocket science.
I apologize, dear colleagues, for being so cranky. Much jollier to be upbeat and amusing. It’s just that, after 40 years in the business, observing the same skull-exploding clinical behaviors gets a little old, along with the observer.
Oren and Ben are fine, though. Oren’s face is as clear as ever. (It’s genetic – his mom has great skin). Even Ben isn’t disturbed. First of all, the rash went away. Second, he has an annual $2,000 drug cost deductible, “so I’d have to spend it anyway.”
“Look, Ben,” I told him, “if you need help exhausting your deductible, I’ll be happy to send you a couple of bills. No problem.”
He smiled. I guess he doesn’t really need my help on that.
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].
Oren is 11. I often see him around the neighborhood.
The other day I gave his father a lift. “Oren had a rash on his face,” said Ben, slipping into the passenger seat. “The pediatrician said she thought it was eczema, but she gave him an acne medicine.”
I raised my eyebrows, but said nothing.
“How much did it cost?” I asked.
“$400.”
“$400!” I couldn’t quite stifle my shock. “What was in the cream?” I asked.
“Here it is,” he said. “I took a picture of the tube on my phone.”
He showed me a snapshot of a tube of clindamycin/benzoyl peroxide.
Although I try not to meddle in the medical issues of friends, I decided to make a small exception in this case. “Next time someone prescribes an expensive skin cream,” I said, “let me know. Maybe I can help you find a more affordable alternative.”
What skin problem did Oren have? I have no idea. I see his face enough to know that he has no acne at all. Nor would acne go away in 2 days.
On the other hand, if he did have a flare of eczema – I’ve never noticed that on him either – acne medicine would aggravate it, if anything.
Besides those questions, I have another one: Regardless of what she thought the diagnosis was, why on earth did Oren’s pediatrician feel compelled to prescribe a $400 generic? I say “compelled” because she told Ben straight out that the cream was going to cost a lot. But she just had to prescribe it because her experience told her it worked.
What experience did she have, exactly? What else had she tried that didn’t work? And what did she mean by “work”?
Ben’s and Oren’s experience is just a small, unnoticed incident of no general interest. It will spur no magazine exposés, incite no lawsuits, launch no professional or political inquiries.
• Oren’s pediatrician will go on prescribing a hideously priced cream intended to treat who-knows-what. Nobody will suggest to her that she might at least consider doing otherwise.
• Pharmacy benefit managers will not crack down on either pediatrician or cream. They have bigger fish to fry, like biologics that cost $50K per year.
• Health care administrators will take no notice. They will instead think up more creative and onerous disincentives to restrain providers from prescribing anything expensive. Whether they will also figure out how to keep monopolistic generic drug manufacturers from jacking up prices into the stratosphere is something else.
• Medical educators will strengthen their focus on sophisticated science (Genomics! Precision Medicine!), while doing a wholly inadequate job of passing on simple lessons that might help primary clinicians do a better job of managing everyday skin problems. Just yesterday, my colleague and I saw two patients who had been taking doxycycline for years with no clinical benefit, three kids with eczema who had used a succession of antifungal creams for over 4 months, one woman who had been dousing herself repeatedly with permethrin – to no avail – because her mites lived exclusively in her brain and those of her prescribers, and a partridge with alopecia in a pear tree. (OK, not the last one). All that in just 1 day!
• Simple common sense will stay elusive. Most rashes are really not rocket science.
I apologize, dear colleagues, for being so cranky. Much jollier to be upbeat and amusing. It’s just that, after 40 years in the business, observing the same skull-exploding clinical behaviors gets a little old, along with the observer.
Oren and Ben are fine, though. Oren’s face is as clear as ever. (It’s genetic – his mom has great skin). Even Ben isn’t disturbed. First of all, the rash went away. Second, he has an annual $2,000 drug cost deductible, “so I’d have to spend it anyway.”
“Look, Ben,” I told him, “if you need help exhausting your deductible, I’ll be happy to send you a couple of bills. No problem.”
He smiled. I guess he doesn’t really need my help on that.
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].
Oren is 11. I often see him around the neighborhood.
The other day I gave his father a lift. “Oren had a rash on his face,” said Ben, slipping into the passenger seat. “The pediatrician said she thought it was eczema, but she gave him an acne medicine.”
I raised my eyebrows, but said nothing.
“How much did it cost?” I asked.
“$400.”
“$400!” I couldn’t quite stifle my shock. “What was in the cream?” I asked.
“Here it is,” he said. “I took a picture of the tube on my phone.”
He showed me a snapshot of a tube of clindamycin/benzoyl peroxide.
Although I try not to meddle in the medical issues of friends, I decided to make a small exception in this case. “Next time someone prescribes an expensive skin cream,” I said, “let me know. Maybe I can help you find a more affordable alternative.”
What skin problem did Oren have? I have no idea. I see his face enough to know that he has no acne at all. Nor would acne go away in 2 days.
On the other hand, if he did have a flare of eczema – I’ve never noticed that on him either – acne medicine would aggravate it, if anything.
Besides those questions, I have another one: Regardless of what she thought the diagnosis was, why on earth did Oren’s pediatrician feel compelled to prescribe a $400 generic? I say “compelled” because she told Ben straight out that the cream was going to cost a lot. But she just had to prescribe it because her experience told her it worked.
What experience did she have, exactly? What else had she tried that didn’t work? And what did she mean by “work”?
Ben’s and Oren’s experience is just a small, unnoticed incident of no general interest. It will spur no magazine exposés, incite no lawsuits, launch no professional or political inquiries.
• Oren’s pediatrician will go on prescribing a hideously priced cream intended to treat who-knows-what. Nobody will suggest to her that she might at least consider doing otherwise.
• Pharmacy benefit managers will not crack down on either pediatrician or cream. They have bigger fish to fry, like biologics that cost $50K per year.
• Health care administrators will take no notice. They will instead think up more creative and onerous disincentives to restrain providers from prescribing anything expensive. Whether they will also figure out how to keep monopolistic generic drug manufacturers from jacking up prices into the stratosphere is something else.
• Medical educators will strengthen their focus on sophisticated science (Genomics! Precision Medicine!), while doing a wholly inadequate job of passing on simple lessons that might help primary clinicians do a better job of managing everyday skin problems. Just yesterday, my colleague and I saw two patients who had been taking doxycycline for years with no clinical benefit, three kids with eczema who had used a succession of antifungal creams for over 4 months, one woman who had been dousing herself repeatedly with permethrin – to no avail – because her mites lived exclusively in her brain and those of her prescribers, and a partridge with alopecia in a pear tree. (OK, not the last one). All that in just 1 day!
• Simple common sense will stay elusive. Most rashes are really not rocket science.
I apologize, dear colleagues, for being so cranky. Much jollier to be upbeat and amusing. It’s just that, after 40 years in the business, observing the same skull-exploding clinical behaviors gets a little old, along with the observer.
Oren and Ben are fine, though. Oren’s face is as clear as ever. (It’s genetic – his mom has great skin). Even Ben isn’t disturbed. First of all, the rash went away. Second, he has an annual $2,000 drug cost deductible, “so I’d have to spend it anyway.”
“Look, Ben,” I told him, “if you need help exhausting your deductible, I’ll be happy to send you a couple of bills. No problem.”
He smiled. I guess he doesn’t really need my help on that.
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].
It’s in the nose
There is a lot more going on in the nose besides air going in and out. The nose is where it all begins for pathogenesis for all respiratory infections. The interplay between the commensal microbes, the potential pathogens, innate immunity, and adaptive immunity is much more complex than was previously understood. So what is new?
In our research on acute otitis media, we swab and wash out noses of children aged 6-36 months to isolate the potential pathogens Streptococcus pneumoniae, nontypeable Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus, and Group A streptococci. We isolate one or more of these bacteria from most of the children even though they are well. We observe perhaps a half-dozen other species of bacteria on the culture plate. Mostly, we isolate S. pneumoniae, nontypeable H. influenza, or M. catarrhalis and alpha-hemolytic streptococci and corynebacterium species.
We have recently begun to investigate the other microbiota in the nose and found they are indeed plentiful. In a recent screening of a half-dozen children, we found hundreds of different microbes in their noses, so cultures and standard molecular detection methods were just touching the surface. I was asked recently at a medical conference – the American Academy of Pediatrics– Orange County, California, annual CME course – at which I spoke on this topic what I thought would be the most-important area of research in the next decade. I responded, the microbiome. The microbiome is indeed a hot topic. Research over the last decade suggests that 90% of all diseases can be traced in some way to disturbances in the microbiome. What I mean by microbiome is “the totality of microorganisms and their collective genetic material present in or on the human body.” The term is often used interchangeably with “microbiota,” although the former refers to genes of microbes and the latter refers to the microbes themselves. What I mean by “disturbance” is excessive use of antibiotics.
How many microbes are in the nose? We don’t know. But if the gut is any indication, there are thousands of microbes in the nose because the gut has more than 10,000 different microbes. Recognizing that there are hundreds of microbes in the nose and from time to time children get colonized by potential pathogens that can cause otitis media, sinusitis, or pneumonia, how does pathogenesis get started? It starts with a respiratory virus infection. The bacteria need help from the viruses to cause disease. The viruses cause damage to the epithelial cells of the nose, and this gives the bacteria more places to attach when they divide so the amount of bacteria increases exponentially. As the viruses replicate, they more effectively slow down cilia beating, and the nasal mucus thickens. This, too, helps the bacteria and viruses attach to and penetrate epithelial cells in the nose and increase in density on the surface of the cells and inside the cells. The viruses divert and/or suppress the innate immune system, represented by neutrophils that migrate to the nose and discharge their intracellular contents to turn nasal mucus yellow and green. The viruses even down-modulate the adaptive immune system in clever ways that result in fewer potentially protective cytotoxic lymphocytes that kill viruses making their way to the nose, and fewer T cells that discharge cytokines that promote a necessary inflammatory response to clear both bacteria and viruses from the nose and fewer B cells that become plasma cells and release antibodies into the nose.
When the bacteria with potential to cause diseases reach a “pathogenic threshold,” they move, along with mucus, into the middle ear, the sinuses, or down the throat to the lungs, usually with the accompanying respiratory virus. There pathogenesis continues in the otherwise sterile and protected sanctuary of these interconnected respiratory sites. A few days later, we as clinicians observe the symptoms and signs of otitis media, sinusitis, or pneumonia.
What can we do to help the nose? Mostly, we should do no harm, and that has been our failing for decades since the introduction of antibiotics. The allure of antibiotics is great because they have indeed saved many lives and shortened many illnesses when appropriately used. However, too often clinicians have seen patients with yellow and green nasal mucus (or any increased nasal mucus) and diagnosed “a bacterial infection” and prescribed antibiotics. And too often clinicians have seen patients with an annoying cough (or any cough) and diagnosed “a bacterial chest infection” and prescribed antibiotics. The clinicians thought it was the right thing to do because they wanted to help their patient. And they did not want them to come back in a few days with persistence or worsening of symptoms, or worse, seek care from other health care providers elsewhere. So they gave antibiotics.
Well, the paradigm has changed. It is now clearly known that antibiotics can be harmful mainly by damaging the normal, healthy microbiome. The change in healthy homeostasis of the microbiome wrought by antibiotics is greatest in newborns, especially premature newborns, then next worst for infants, and then next worst for young children. These are the age groups where antibiotics are prescribed most frequently! And everyone needs to stop writing those prescriptions for runny noses, yellow and green mucus in the nose, and coughs. All of us need to prescribe antibiotics only when there is an accurate diagnosis of otitis media or sinusitis or bronchopneumonia or lobar pneumonia. And when we do prescribe the antibiotics ,we need to give them for as short a time as possible. But that is a topic for another column.
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he has no relevant financial disclosures, and that his research is supported by a grant from the National Institutes of Health National Institute of Deafness and Communication Disorders. Email him at [email protected].
There is a lot more going on in the nose besides air going in and out. The nose is where it all begins for pathogenesis for all respiratory infections. The interplay between the commensal microbes, the potential pathogens, innate immunity, and adaptive immunity is much more complex than was previously understood. So what is new?
In our research on acute otitis media, we swab and wash out noses of children aged 6-36 months to isolate the potential pathogens Streptococcus pneumoniae, nontypeable Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus, and Group A streptococci. We isolate one or more of these bacteria from most of the children even though they are well. We observe perhaps a half-dozen other species of bacteria on the culture plate. Mostly, we isolate S. pneumoniae, nontypeable H. influenza, or M. catarrhalis and alpha-hemolytic streptococci and corynebacterium species.
We have recently begun to investigate the other microbiota in the nose and found they are indeed plentiful. In a recent screening of a half-dozen children, we found hundreds of different microbes in their noses, so cultures and standard molecular detection methods were just touching the surface. I was asked recently at a medical conference – the American Academy of Pediatrics– Orange County, California, annual CME course – at which I spoke on this topic what I thought would be the most-important area of research in the next decade. I responded, the microbiome. The microbiome is indeed a hot topic. Research over the last decade suggests that 90% of all diseases can be traced in some way to disturbances in the microbiome. What I mean by microbiome is “the totality of microorganisms and their collective genetic material present in or on the human body.” The term is often used interchangeably with “microbiota,” although the former refers to genes of microbes and the latter refers to the microbes themselves. What I mean by “disturbance” is excessive use of antibiotics.
How many microbes are in the nose? We don’t know. But if the gut is any indication, there are thousands of microbes in the nose because the gut has more than 10,000 different microbes. Recognizing that there are hundreds of microbes in the nose and from time to time children get colonized by potential pathogens that can cause otitis media, sinusitis, or pneumonia, how does pathogenesis get started? It starts with a respiratory virus infection. The bacteria need help from the viruses to cause disease. The viruses cause damage to the epithelial cells of the nose, and this gives the bacteria more places to attach when they divide so the amount of bacteria increases exponentially. As the viruses replicate, they more effectively slow down cilia beating, and the nasal mucus thickens. This, too, helps the bacteria and viruses attach to and penetrate epithelial cells in the nose and increase in density on the surface of the cells and inside the cells. The viruses divert and/or suppress the innate immune system, represented by neutrophils that migrate to the nose and discharge their intracellular contents to turn nasal mucus yellow and green. The viruses even down-modulate the adaptive immune system in clever ways that result in fewer potentially protective cytotoxic lymphocytes that kill viruses making their way to the nose, and fewer T cells that discharge cytokines that promote a necessary inflammatory response to clear both bacteria and viruses from the nose and fewer B cells that become plasma cells and release antibodies into the nose.
When the bacteria with potential to cause diseases reach a “pathogenic threshold,” they move, along with mucus, into the middle ear, the sinuses, or down the throat to the lungs, usually with the accompanying respiratory virus. There pathogenesis continues in the otherwise sterile and protected sanctuary of these interconnected respiratory sites. A few days later, we as clinicians observe the symptoms and signs of otitis media, sinusitis, or pneumonia.
What can we do to help the nose? Mostly, we should do no harm, and that has been our failing for decades since the introduction of antibiotics. The allure of antibiotics is great because they have indeed saved many lives and shortened many illnesses when appropriately used. However, too often clinicians have seen patients with yellow and green nasal mucus (or any increased nasal mucus) and diagnosed “a bacterial infection” and prescribed antibiotics. And too often clinicians have seen patients with an annoying cough (or any cough) and diagnosed “a bacterial chest infection” and prescribed antibiotics. The clinicians thought it was the right thing to do because they wanted to help their patient. And they did not want them to come back in a few days with persistence or worsening of symptoms, or worse, seek care from other health care providers elsewhere. So they gave antibiotics.
Well, the paradigm has changed. It is now clearly known that antibiotics can be harmful mainly by damaging the normal, healthy microbiome. The change in healthy homeostasis of the microbiome wrought by antibiotics is greatest in newborns, especially premature newborns, then next worst for infants, and then next worst for young children. These are the age groups where antibiotics are prescribed most frequently! And everyone needs to stop writing those prescriptions for runny noses, yellow and green mucus in the nose, and coughs. All of us need to prescribe antibiotics only when there is an accurate diagnosis of otitis media or sinusitis or bronchopneumonia or lobar pneumonia. And when we do prescribe the antibiotics ,we need to give them for as short a time as possible. But that is a topic for another column.
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he has no relevant financial disclosures, and that his research is supported by a grant from the National Institutes of Health National Institute of Deafness and Communication Disorders. Email him at [email protected].
There is a lot more going on in the nose besides air going in and out. The nose is where it all begins for pathogenesis for all respiratory infections. The interplay between the commensal microbes, the potential pathogens, innate immunity, and adaptive immunity is much more complex than was previously understood. So what is new?
In our research on acute otitis media, we swab and wash out noses of children aged 6-36 months to isolate the potential pathogens Streptococcus pneumoniae, nontypeable Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus, and Group A streptococci. We isolate one or more of these bacteria from most of the children even though they are well. We observe perhaps a half-dozen other species of bacteria on the culture plate. Mostly, we isolate S. pneumoniae, nontypeable H. influenza, or M. catarrhalis and alpha-hemolytic streptococci and corynebacterium species.
We have recently begun to investigate the other microbiota in the nose and found they are indeed plentiful. In a recent screening of a half-dozen children, we found hundreds of different microbes in their noses, so cultures and standard molecular detection methods were just touching the surface. I was asked recently at a medical conference – the American Academy of Pediatrics– Orange County, California, annual CME course – at which I spoke on this topic what I thought would be the most-important area of research in the next decade. I responded, the microbiome. The microbiome is indeed a hot topic. Research over the last decade suggests that 90% of all diseases can be traced in some way to disturbances in the microbiome. What I mean by microbiome is “the totality of microorganisms and their collective genetic material present in or on the human body.” The term is often used interchangeably with “microbiota,” although the former refers to genes of microbes and the latter refers to the microbes themselves. What I mean by “disturbance” is excessive use of antibiotics.
How many microbes are in the nose? We don’t know. But if the gut is any indication, there are thousands of microbes in the nose because the gut has more than 10,000 different microbes. Recognizing that there are hundreds of microbes in the nose and from time to time children get colonized by potential pathogens that can cause otitis media, sinusitis, or pneumonia, how does pathogenesis get started? It starts with a respiratory virus infection. The bacteria need help from the viruses to cause disease. The viruses cause damage to the epithelial cells of the nose, and this gives the bacteria more places to attach when they divide so the amount of bacteria increases exponentially. As the viruses replicate, they more effectively slow down cilia beating, and the nasal mucus thickens. This, too, helps the bacteria and viruses attach to and penetrate epithelial cells in the nose and increase in density on the surface of the cells and inside the cells. The viruses divert and/or suppress the innate immune system, represented by neutrophils that migrate to the nose and discharge their intracellular contents to turn nasal mucus yellow and green. The viruses even down-modulate the adaptive immune system in clever ways that result in fewer potentially protective cytotoxic lymphocytes that kill viruses making their way to the nose, and fewer T cells that discharge cytokines that promote a necessary inflammatory response to clear both bacteria and viruses from the nose and fewer B cells that become plasma cells and release antibodies into the nose.
When the bacteria with potential to cause diseases reach a “pathogenic threshold,” they move, along with mucus, into the middle ear, the sinuses, or down the throat to the lungs, usually with the accompanying respiratory virus. There pathogenesis continues in the otherwise sterile and protected sanctuary of these interconnected respiratory sites. A few days later, we as clinicians observe the symptoms and signs of otitis media, sinusitis, or pneumonia.
What can we do to help the nose? Mostly, we should do no harm, and that has been our failing for decades since the introduction of antibiotics. The allure of antibiotics is great because they have indeed saved many lives and shortened many illnesses when appropriately used. However, too often clinicians have seen patients with yellow and green nasal mucus (or any increased nasal mucus) and diagnosed “a bacterial infection” and prescribed antibiotics. And too often clinicians have seen patients with an annoying cough (or any cough) and diagnosed “a bacterial chest infection” and prescribed antibiotics. The clinicians thought it was the right thing to do because they wanted to help their patient. And they did not want them to come back in a few days with persistence or worsening of symptoms, or worse, seek care from other health care providers elsewhere. So they gave antibiotics.
Well, the paradigm has changed. It is now clearly known that antibiotics can be harmful mainly by damaging the normal, healthy microbiome. The change in healthy homeostasis of the microbiome wrought by antibiotics is greatest in newborns, especially premature newborns, then next worst for infants, and then next worst for young children. These are the age groups where antibiotics are prescribed most frequently! And everyone needs to stop writing those prescriptions for runny noses, yellow and green mucus in the nose, and coughs. All of us need to prescribe antibiotics only when there is an accurate diagnosis of otitis media or sinusitis or bronchopneumonia or lobar pneumonia. And when we do prescribe the antibiotics ,we need to give them for as short a time as possible. But that is a topic for another column.
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he has no relevant financial disclosures, and that his research is supported by a grant from the National Institutes of Health National Institute of Deafness and Communication Disorders. Email him at [email protected].
Financial mental health: A framework for improving patients’ lives
The following opinions are my own and not those of the U.S. Department of Defense.
Job insecurity can have a powerful impact on health, particularly mental health.
A recent study of almost 17,500 U.S. working adults found that 33% of the workers thought that their jobs were insecure, and those who reported job insecurity were more likely to be obese, sleep less than 6 hours a day, report pain conditions, and smoke every day. When it came to mental health, those who were job insecure had a likelihood of serious mental illness within the last 30 days almost five times higher than those who were not job insecure (J Community Health. 2016 Sep 10. doi: 10.1007/s10900-016-0249-8). This study is one of many that highlights the importance of what I call “financial mental health.”
The notion of financial mental health merges two distinct, yet interrelated aspects of patients’ lives into a single construct that can be used to inform resiliency-building behaviors and identify gaps in institutional approaches to supportive services. Patients with strong financial mental health are able to build, maintain, sustain, and revitalize their resiliency across several domains, which include mind, body, spirit, and social indicators.
Financial mental health and mortality
According to the World Bank, “Mental health issues impose an enormous disease burden on societies across the world. Depression alone affects 350 million people globally and is the leading cause of disability worldwide. Despite its enormous social burden, mental disorders continue to be driven into the shadows by stigma, prejudice, and fear. The issue is becoming ever more urgent in light of the forced migration and sustained conflict we are seeing in many countries around the world.”1 In the United States alone, the Consumer Financial Protection Bureau (CFPB) reports that almost one-third of Americans are touched by poverty and advocates for financial literacy and empowerment for our most vulnerable citizens.
Unfortunately, mental health clinicians rarely discuss a depressed patient’s financial planning aside from occasional referrals for housing, disability benefits, or subsistence allowances. Based on observations from the World Health Organization, mental health is tied to satisfaction with quality of life. Furthermore, it relates to the ability to cope with life’s stressors, to engage in meaningful and productive activities, and to have a sense of community belonging.
When Abraham Maslow, PhD, described psychological health through the lens of human motivation, he constructed a “hierarchy of needs”2 that at the base lies the physiological requirements for food, shelter, and clothing. Those items represent our most physical necessities, protect us from harm, and determine our survival. They also are related to our need for safety (i.e., job security), which is the second rung on Dr. Maslow’s hierarchy of needs. In many ways, our ability to feel safe is predicated on our ability to secure our environment with proper housing, healthy nutrition, and appropriate wardrobe (and the accouterments thereof), which, in turn, align us and our families to our culture, community, and socioeconomic status. But it costs money to stay healthy and protected. The CFPB recognized the intersection of these issues and developed a toolkit3 for social service and related agencies aimed at enhancing financial literacy and education within the populations they serve so that those individuals can become more skilled and empowered.
The consequences of poor financial mental health are found in data related to mortality. The Centers for Disease Control and Prevention documents that lower socioeconomic status is related to higher rates of mortality.4 For Americans living in poverty, their social network, lifestyle, and access to medical care contribute to their inability to live longer lives. Without access to quality and timely medical care, and appropriately funded services, the impacts from trauma, depression, substance abuse, and suicide are more widely experienced. For example, the Department of Defense Suicide Event Report since 2008 has linked suicide and suicide attempts among Service members to failed relationships along with financial and legal problems.
Several of the economic issues relate to conflicts in the workplace that can determine promotions in rank/increases in pay, retention, or transition to civilian employment/unemployment, retirement pay and benefits, or disability compensation. Service members and their families also are subject to divorce and alimony, child support payments, student loan repayments, mortgage defaults, and other liens or judgments. As veterans, this younger cohort must secure new housing, enroll in college or gain employment. This means (often for the first time) financing a mortgage, hunting for a job, filing for GI Bill or other Department of Veterans Affairs (VA) benefits, updating insurance, and family budgeting, while also dealing with the stress of military separation and loss of service identity, and postdeployment health issues. The VA has studied increases in suicide rates, depression, and post-traumatic stress disorder within this population – which is not surprising given the level of social instability that they are experiencing.
Furthermore, for veterans who seek treatment, which can mean long inpatient hospitalization or rehabilitation stays, numerous outpatient appointments, and/or medication management, there will be an impact on their finances, because they will be limited in their ability to maintain gainful employment or enroll in classes. This, in turn, complicates family dynamics. Sometimes, spouses have to assume caregiver roles or become the primary breadwinner, which can have an effect on veterans’ self-esteem, sense of belongingness, and burdensomeness – factors associated with suicide.
Mental health also is affected by financial abuse. According to the National Network to End Domestic Violence, financial abuse is a means by which perpetrators can control their victims who are elderly, disabled, subjects of human trafficking, or their partners. Although financial abuse occurs across all socioeconomic classes, usually victims who are experiencing physical and emotional abuse also are being controlled by having their finances or assets taken or withheld from them. Survivors able to extricate themselves from an abuser often are dealing with depression, anxiety, substance abuse, or suicidality. Under that state of mind, they also must find ways to repair their employability and insurability, recover from debt or identity theft, restore their credit and rebuild assets, file for divorce or protective orders, or claim unpaid alimony or child support from the perpetrator and secure safe housing – all while managing their symptoms.
Concrete steps
Individuals can take steps to ensure their financial mental health. Looking at Dr. Maslow’s hierarchy, the pinnacle of the pyramid centers on activities that relate to self-efficacy and esteem. Financial planning is an activity that can foster those feelings but requires the right blend of knowledge and information. Investing in the market has been described as an emotional experience. When the market is up and risk is high, emotions are positive; but when it is low, despondency over a portfolio can set in, and emotions may run scared. Investing comes with its risks and rewards. The receptiveness that individuals have for financial planning and investing will depend upon their views about tolerating risk, as well as their lifestyle goals and objectives, retirement plans, and health concerns.
Trauma survivors who tend to experience anxiety, depression, guilt, or emotional numbing – and have a foreshortened sense of future – may find it difficult to focus on a long-term financial plan. In the early stages of therapy and recovery, finance efforts may need to be concentrated primarily on obtaining a job with benefits and proper housing. Reducing debt and restoring credit become secondary challenges, and investing and retirement planning may take an even further backseat. However, for those experiencing psychological challenges, financial planning can be empowering and reassuring, because it provides a sense of structure, identifies goals, and restores hope for a better future.
Communities and organizations that support individuals with psychiatric conditions may need to further consider embedding financial planning into a case management approach that is more holistic and concentrates on all domains of social resilience as recommended by the CFPB. Training clinicians about financial planning can be useful because of the tools it can offer patients who are working on their recovery and rebuilding their futures.
People contemplating suicide are known to first get their affairs in order and often will update their beneficiary status, sometime making multiple changes depending on their emotional state within a month of their death, so agents should be aware of these habits. When working with veterans, abuse survivors, or those with more serious mental illness, ensuring that they are knowledgeable about available government benefits and pairing them with private sector products can help people who might seem like they are in denial or procrastinating about investing but are actually feeling overwhelmed, confused, and lack confidence in their own decision making. Partitioning these goals into short- and long-term steps and providing more attentive case management that builds trust and addresses concerns can help people stay engaged in reaching their goals.
Financial mental health is a concept rooted in individual resilience and the approaches needed to maximize it. As mental health professionals, we can leverage our own knowledge with that of personal finance experts to help our patients build resilience skills and tools. As result, patients in the most disadvantaged and disenfranchised communities will not only survive but thrive.
References
1 “Out of the Shadows: Making Mental Health a Global Priority,” April 13-14, 2016.
2 Psychological Rev. 1943;50:370-96. “A Theory of Human Motivation” is represented as a pyramid with the most fundamental needs at the base. Those needs are physiological, safety, love/belonging, esteem, and self-actualization in descending order.
3 “Your Money, Your Goals: A financial empowerment toolkit for Social Services programs,” April 2015.
4 National Vital Statistics Report, “Deaths: Final Data for 2014,” Vol. 65 No. 4, June 30, 2016.
Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and, suicide prevention and peer support programs; worked with Gulf War veterans as an Army social work officer; and provided individual, group, and family therapy to Vietnam veterans their families dealing with post-traumatic stress disorder.
The following opinions are my own and not those of the U.S. Department of Defense.
Job insecurity can have a powerful impact on health, particularly mental health.
A recent study of almost 17,500 U.S. working adults found that 33% of the workers thought that their jobs were insecure, and those who reported job insecurity were more likely to be obese, sleep less than 6 hours a day, report pain conditions, and smoke every day. When it came to mental health, those who were job insecure had a likelihood of serious mental illness within the last 30 days almost five times higher than those who were not job insecure (J Community Health. 2016 Sep 10. doi: 10.1007/s10900-016-0249-8). This study is one of many that highlights the importance of what I call “financial mental health.”
The notion of financial mental health merges two distinct, yet interrelated aspects of patients’ lives into a single construct that can be used to inform resiliency-building behaviors and identify gaps in institutional approaches to supportive services. Patients with strong financial mental health are able to build, maintain, sustain, and revitalize their resiliency across several domains, which include mind, body, spirit, and social indicators.
Financial mental health and mortality
According to the World Bank, “Mental health issues impose an enormous disease burden on societies across the world. Depression alone affects 350 million people globally and is the leading cause of disability worldwide. Despite its enormous social burden, mental disorders continue to be driven into the shadows by stigma, prejudice, and fear. The issue is becoming ever more urgent in light of the forced migration and sustained conflict we are seeing in many countries around the world.”1 In the United States alone, the Consumer Financial Protection Bureau (CFPB) reports that almost one-third of Americans are touched by poverty and advocates for financial literacy and empowerment for our most vulnerable citizens.
Unfortunately, mental health clinicians rarely discuss a depressed patient’s financial planning aside from occasional referrals for housing, disability benefits, or subsistence allowances. Based on observations from the World Health Organization, mental health is tied to satisfaction with quality of life. Furthermore, it relates to the ability to cope with life’s stressors, to engage in meaningful and productive activities, and to have a sense of community belonging.
When Abraham Maslow, PhD, described psychological health through the lens of human motivation, he constructed a “hierarchy of needs”2 that at the base lies the physiological requirements for food, shelter, and clothing. Those items represent our most physical necessities, protect us from harm, and determine our survival. They also are related to our need for safety (i.e., job security), which is the second rung on Dr. Maslow’s hierarchy of needs. In many ways, our ability to feel safe is predicated on our ability to secure our environment with proper housing, healthy nutrition, and appropriate wardrobe (and the accouterments thereof), which, in turn, align us and our families to our culture, community, and socioeconomic status. But it costs money to stay healthy and protected. The CFPB recognized the intersection of these issues and developed a toolkit3 for social service and related agencies aimed at enhancing financial literacy and education within the populations they serve so that those individuals can become more skilled and empowered.
The consequences of poor financial mental health are found in data related to mortality. The Centers for Disease Control and Prevention documents that lower socioeconomic status is related to higher rates of mortality.4 For Americans living in poverty, their social network, lifestyle, and access to medical care contribute to their inability to live longer lives. Without access to quality and timely medical care, and appropriately funded services, the impacts from trauma, depression, substance abuse, and suicide are more widely experienced. For example, the Department of Defense Suicide Event Report since 2008 has linked suicide and suicide attempts among Service members to failed relationships along with financial and legal problems.
Several of the economic issues relate to conflicts in the workplace that can determine promotions in rank/increases in pay, retention, or transition to civilian employment/unemployment, retirement pay and benefits, or disability compensation. Service members and their families also are subject to divorce and alimony, child support payments, student loan repayments, mortgage defaults, and other liens or judgments. As veterans, this younger cohort must secure new housing, enroll in college or gain employment. This means (often for the first time) financing a mortgage, hunting for a job, filing for GI Bill or other Department of Veterans Affairs (VA) benefits, updating insurance, and family budgeting, while also dealing with the stress of military separation and loss of service identity, and postdeployment health issues. The VA has studied increases in suicide rates, depression, and post-traumatic stress disorder within this population – which is not surprising given the level of social instability that they are experiencing.
Furthermore, for veterans who seek treatment, which can mean long inpatient hospitalization or rehabilitation stays, numerous outpatient appointments, and/or medication management, there will be an impact on their finances, because they will be limited in their ability to maintain gainful employment or enroll in classes. This, in turn, complicates family dynamics. Sometimes, spouses have to assume caregiver roles or become the primary breadwinner, which can have an effect on veterans’ self-esteem, sense of belongingness, and burdensomeness – factors associated with suicide.
Mental health also is affected by financial abuse. According to the National Network to End Domestic Violence, financial abuse is a means by which perpetrators can control their victims who are elderly, disabled, subjects of human trafficking, or their partners. Although financial abuse occurs across all socioeconomic classes, usually victims who are experiencing physical and emotional abuse also are being controlled by having their finances or assets taken or withheld from them. Survivors able to extricate themselves from an abuser often are dealing with depression, anxiety, substance abuse, or suicidality. Under that state of mind, they also must find ways to repair their employability and insurability, recover from debt or identity theft, restore their credit and rebuild assets, file for divorce or protective orders, or claim unpaid alimony or child support from the perpetrator and secure safe housing – all while managing their symptoms.
Concrete steps
Individuals can take steps to ensure their financial mental health. Looking at Dr. Maslow’s hierarchy, the pinnacle of the pyramid centers on activities that relate to self-efficacy and esteem. Financial planning is an activity that can foster those feelings but requires the right blend of knowledge and information. Investing in the market has been described as an emotional experience. When the market is up and risk is high, emotions are positive; but when it is low, despondency over a portfolio can set in, and emotions may run scared. Investing comes with its risks and rewards. The receptiveness that individuals have for financial planning and investing will depend upon their views about tolerating risk, as well as their lifestyle goals and objectives, retirement plans, and health concerns.
Trauma survivors who tend to experience anxiety, depression, guilt, or emotional numbing – and have a foreshortened sense of future – may find it difficult to focus on a long-term financial plan. In the early stages of therapy and recovery, finance efforts may need to be concentrated primarily on obtaining a job with benefits and proper housing. Reducing debt and restoring credit become secondary challenges, and investing and retirement planning may take an even further backseat. However, for those experiencing psychological challenges, financial planning can be empowering and reassuring, because it provides a sense of structure, identifies goals, and restores hope for a better future.
Communities and organizations that support individuals with psychiatric conditions may need to further consider embedding financial planning into a case management approach that is more holistic and concentrates on all domains of social resilience as recommended by the CFPB. Training clinicians about financial planning can be useful because of the tools it can offer patients who are working on their recovery and rebuilding their futures.
People contemplating suicide are known to first get their affairs in order and often will update their beneficiary status, sometime making multiple changes depending on their emotional state within a month of their death, so agents should be aware of these habits. When working with veterans, abuse survivors, or those with more serious mental illness, ensuring that they are knowledgeable about available government benefits and pairing them with private sector products can help people who might seem like they are in denial or procrastinating about investing but are actually feeling overwhelmed, confused, and lack confidence in their own decision making. Partitioning these goals into short- and long-term steps and providing more attentive case management that builds trust and addresses concerns can help people stay engaged in reaching their goals.
Financial mental health is a concept rooted in individual resilience and the approaches needed to maximize it. As mental health professionals, we can leverage our own knowledge with that of personal finance experts to help our patients build resilience skills and tools. As result, patients in the most disadvantaged and disenfranchised communities will not only survive but thrive.
References
1 “Out of the Shadows: Making Mental Health a Global Priority,” April 13-14, 2016.
2 Psychological Rev. 1943;50:370-96. “A Theory of Human Motivation” is represented as a pyramid with the most fundamental needs at the base. Those needs are physiological, safety, love/belonging, esteem, and self-actualization in descending order.
3 “Your Money, Your Goals: A financial empowerment toolkit for Social Services programs,” April 2015.
4 National Vital Statistics Report, “Deaths: Final Data for 2014,” Vol. 65 No. 4, June 30, 2016.
Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and, suicide prevention and peer support programs; worked with Gulf War veterans as an Army social work officer; and provided individual, group, and family therapy to Vietnam veterans their families dealing with post-traumatic stress disorder.
The following opinions are my own and not those of the U.S. Department of Defense.
Job insecurity can have a powerful impact on health, particularly mental health.
A recent study of almost 17,500 U.S. working adults found that 33% of the workers thought that their jobs were insecure, and those who reported job insecurity were more likely to be obese, sleep less than 6 hours a day, report pain conditions, and smoke every day. When it came to mental health, those who were job insecure had a likelihood of serious mental illness within the last 30 days almost five times higher than those who were not job insecure (J Community Health. 2016 Sep 10. doi: 10.1007/s10900-016-0249-8). This study is one of many that highlights the importance of what I call “financial mental health.”
The notion of financial mental health merges two distinct, yet interrelated aspects of patients’ lives into a single construct that can be used to inform resiliency-building behaviors and identify gaps in institutional approaches to supportive services. Patients with strong financial mental health are able to build, maintain, sustain, and revitalize their resiliency across several domains, which include mind, body, spirit, and social indicators.
Financial mental health and mortality
According to the World Bank, “Mental health issues impose an enormous disease burden on societies across the world. Depression alone affects 350 million people globally and is the leading cause of disability worldwide. Despite its enormous social burden, mental disorders continue to be driven into the shadows by stigma, prejudice, and fear. The issue is becoming ever more urgent in light of the forced migration and sustained conflict we are seeing in many countries around the world.”1 In the United States alone, the Consumer Financial Protection Bureau (CFPB) reports that almost one-third of Americans are touched by poverty and advocates for financial literacy and empowerment for our most vulnerable citizens.
Unfortunately, mental health clinicians rarely discuss a depressed patient’s financial planning aside from occasional referrals for housing, disability benefits, or subsistence allowances. Based on observations from the World Health Organization, mental health is tied to satisfaction with quality of life. Furthermore, it relates to the ability to cope with life’s stressors, to engage in meaningful and productive activities, and to have a sense of community belonging.
When Abraham Maslow, PhD, described psychological health through the lens of human motivation, he constructed a “hierarchy of needs”2 that at the base lies the physiological requirements for food, shelter, and clothing. Those items represent our most physical necessities, protect us from harm, and determine our survival. They also are related to our need for safety (i.e., job security), which is the second rung on Dr. Maslow’s hierarchy of needs. In many ways, our ability to feel safe is predicated on our ability to secure our environment with proper housing, healthy nutrition, and appropriate wardrobe (and the accouterments thereof), which, in turn, align us and our families to our culture, community, and socioeconomic status. But it costs money to stay healthy and protected. The CFPB recognized the intersection of these issues and developed a toolkit3 for social service and related agencies aimed at enhancing financial literacy and education within the populations they serve so that those individuals can become more skilled and empowered.
The consequences of poor financial mental health are found in data related to mortality. The Centers for Disease Control and Prevention documents that lower socioeconomic status is related to higher rates of mortality.4 For Americans living in poverty, their social network, lifestyle, and access to medical care contribute to their inability to live longer lives. Without access to quality and timely medical care, and appropriately funded services, the impacts from trauma, depression, substance abuse, and suicide are more widely experienced. For example, the Department of Defense Suicide Event Report since 2008 has linked suicide and suicide attempts among Service members to failed relationships along with financial and legal problems.
Several of the economic issues relate to conflicts in the workplace that can determine promotions in rank/increases in pay, retention, or transition to civilian employment/unemployment, retirement pay and benefits, or disability compensation. Service members and their families also are subject to divorce and alimony, child support payments, student loan repayments, mortgage defaults, and other liens or judgments. As veterans, this younger cohort must secure new housing, enroll in college or gain employment. This means (often for the first time) financing a mortgage, hunting for a job, filing for GI Bill or other Department of Veterans Affairs (VA) benefits, updating insurance, and family budgeting, while also dealing with the stress of military separation and loss of service identity, and postdeployment health issues. The VA has studied increases in suicide rates, depression, and post-traumatic stress disorder within this population – which is not surprising given the level of social instability that they are experiencing.
Furthermore, for veterans who seek treatment, which can mean long inpatient hospitalization or rehabilitation stays, numerous outpatient appointments, and/or medication management, there will be an impact on their finances, because they will be limited in their ability to maintain gainful employment or enroll in classes. This, in turn, complicates family dynamics. Sometimes, spouses have to assume caregiver roles or become the primary breadwinner, which can have an effect on veterans’ self-esteem, sense of belongingness, and burdensomeness – factors associated with suicide.
Mental health also is affected by financial abuse. According to the National Network to End Domestic Violence, financial abuse is a means by which perpetrators can control their victims who are elderly, disabled, subjects of human trafficking, or their partners. Although financial abuse occurs across all socioeconomic classes, usually victims who are experiencing physical and emotional abuse also are being controlled by having their finances or assets taken or withheld from them. Survivors able to extricate themselves from an abuser often are dealing with depression, anxiety, substance abuse, or suicidality. Under that state of mind, they also must find ways to repair their employability and insurability, recover from debt or identity theft, restore their credit and rebuild assets, file for divorce or protective orders, or claim unpaid alimony or child support from the perpetrator and secure safe housing – all while managing their symptoms.
Concrete steps
Individuals can take steps to ensure their financial mental health. Looking at Dr. Maslow’s hierarchy, the pinnacle of the pyramid centers on activities that relate to self-efficacy and esteem. Financial planning is an activity that can foster those feelings but requires the right blend of knowledge and information. Investing in the market has been described as an emotional experience. When the market is up and risk is high, emotions are positive; but when it is low, despondency over a portfolio can set in, and emotions may run scared. Investing comes with its risks and rewards. The receptiveness that individuals have for financial planning and investing will depend upon their views about tolerating risk, as well as their lifestyle goals and objectives, retirement plans, and health concerns.
Trauma survivors who tend to experience anxiety, depression, guilt, or emotional numbing – and have a foreshortened sense of future – may find it difficult to focus on a long-term financial plan. In the early stages of therapy and recovery, finance efforts may need to be concentrated primarily on obtaining a job with benefits and proper housing. Reducing debt and restoring credit become secondary challenges, and investing and retirement planning may take an even further backseat. However, for those experiencing psychological challenges, financial planning can be empowering and reassuring, because it provides a sense of structure, identifies goals, and restores hope for a better future.
Communities and organizations that support individuals with psychiatric conditions may need to further consider embedding financial planning into a case management approach that is more holistic and concentrates on all domains of social resilience as recommended by the CFPB. Training clinicians about financial planning can be useful because of the tools it can offer patients who are working on their recovery and rebuilding their futures.
People contemplating suicide are known to first get their affairs in order and often will update their beneficiary status, sometime making multiple changes depending on their emotional state within a month of their death, so agents should be aware of these habits. When working with veterans, abuse survivors, or those with more serious mental illness, ensuring that they are knowledgeable about available government benefits and pairing them with private sector products can help people who might seem like they are in denial or procrastinating about investing but are actually feeling overwhelmed, confused, and lack confidence in their own decision making. Partitioning these goals into short- and long-term steps and providing more attentive case management that builds trust and addresses concerns can help people stay engaged in reaching their goals.
Financial mental health is a concept rooted in individual resilience and the approaches needed to maximize it. As mental health professionals, we can leverage our own knowledge with that of personal finance experts to help our patients build resilience skills and tools. As result, patients in the most disadvantaged and disenfranchised communities will not only survive but thrive.
References
1 “Out of the Shadows: Making Mental Health a Global Priority,” April 13-14, 2016.
2 Psychological Rev. 1943;50:370-96. “A Theory of Human Motivation” is represented as a pyramid with the most fundamental needs at the base. Those needs are physiological, safety, love/belonging, esteem, and self-actualization in descending order.
3 “Your Money, Your Goals: A financial empowerment toolkit for Social Services programs,” April 2015.
4 National Vital Statistics Report, “Deaths: Final Data for 2014,” Vol. 65 No. 4, June 30, 2016.
Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and, suicide prevention and peer support programs; worked with Gulf War veterans as an Army social work officer; and provided individual, group, and family therapy to Vietnam veterans their families dealing with post-traumatic stress disorder.