Direction Behavioral Health Associates, LLC

Stop Doing That: Why Parents Sometimes Need to Get Out of the Way

Thu, 18 Jun 2026 17:14:40 GMT

Parents naturally want to help their children succeed. When a child is struggling - whether with school, friendships, anxiety, or motivation - the instinct is often to step in, solve problems, and remove obstacles. Over the years, both as a teacher and now as a therapist, I've found that some of the most effective parenting advice can be surprisingly simple: Stop doing that.

I spent nearly two decades teaching health before becoming a therapist. Throughout my career, I've been less interested in telling young people what to think and more interested in helping them learn how to think through challenges for themselves. Today, I bring that same philosophy to my work with adolescents and families.

One lesson I've learned repeatedly is that parents often unintentionally make problems more complicated than they need to be. In parenting groups, I frequently hear parents describe elaborate systems they've created to help their children succeed: special study spaces, carefully selected planners, constant reminders, and ongoing monitoring of schoolwork. While these efforts come from a place of love, they often shift responsibility away from the child and onto the parent.

I once worked with a mother who was deeply concerned about her daughter's academic performance. Week after week, she described new strategies she was implementing to help her daughter complete homework and improve grades. She found the perfect desk. Then the perfect planner. Then the perfect pens.

As we talked, it became clear that we were focusing on the wrong problem. So I gave her some rather simple advice:

"Stop doing that."

The point wasn't that she should stop caring. Quite the opposite. What I saw was a parent working incredibly hard to solve a problem that ultimately belonged to her daughter. By managing every detail, she was preventing her daughter from experiencing the natural consequences of her choices and learning how to navigate challenges independently.

This reflects a broader principle we often discuss at Direction Behavioral Health: maximum support, minimum interference . Parents can remain loving, supportive, and involved while still allowing their children to face the outcomes of their decisions. If a student doesn't complete homework, the resulting grade becomes valuable feedback. If a teenager is struggling socially or emotionally, the goal is not to eliminate every discomfort but to help them develop the skills to manage those difficulties themselves.

One of the greatest risks of excessive involvement is the impact it can have on the parent-child relationship. When parents constantly monitor, remind, pressure, or control, interactions begin revolving around performance rather than connection. Conversations become about grades, assignments, or behavior instead of understanding the child as a person. Over time, children may become less likely to seek support when they genuinely need it because they associate their parents with pressure rather than partnership.

I've observed this shift not only as a therapist but also as an educator. Over the years, parents gained increasing access to their children's academic lives through online grade portals and real-time school updates. While that visibility can be helpful, the trade-off is that it sometimes replaces direct conversations between parents and children. Instead of asking, "How's school going?" parents may focus on what they're seeing online, turning academic performance into the primary measure of well-being.

The solution is not to become uninvolved. Rather, I encourage parents to focus on their long-term goals for their children. Before stepping in, it can be helpful to ask: Will this action help my child develop the skills necessary to become a capable, healthy, independent adult five or ten years from now?

Often, the actions that provide immediate relief in the short term can create greater challenges in the long term. Rescuing a child from every mistake may prevent them from developing resilience, responsibility, and problem-solving skills. Allowing them to struggle, while offering support and guidance, gives them the opportunity to learn.

Parenting will always involve difficult decisions and uncomfortable moments. Watching a child fail, make mistakes, or experience disappointment is never easy. I don't want to minimize how painful that can be. At the same time, some of the most meaningful growth happens when parents resist the urge to fix everything and instead create space for their children to learn from their experiences.

Sometimes, the most supportive thing a parent can do is not to do more, but to do less. In the end, our children grow not from what we do for them, but from what they learn to do for themselves.

Why Kids Should Play with Sticks

Mon, 15 Jun 2026 18:40:27 GMT

Go to any playground, park or outdoor area with kids and you will hear a chorus of adults intermittently shouting, “Put that down!” Look nearby and you will see some child with a stick which, if he has been successful in his playtime mission, is likely larger than he is tall.

I would like to challenge the naysaying adult to quit her barrage of commands and challenge her child to find an even bigger stick then whack a tree and in the process find and build his physical strength as well as his emotional resilience.

The Disappearing Art of Unstructured Play

Modern childhood looks very different than it did even twenty years ago.

Children spend more time indoors, more time on screens, and more time in adult-directed activities. Sports, lessons, practices, tutoring, and structured entertainment have largely replaced the long stretches of free play that previous generations experienced.

Parents are under tremendous pressure to keep children safe and feel responsible for their success. But in our effort to protect kids from every possible risk, we are unintentionally preventing them from developing the skills they need most. Paradoxically, we even prevent them from developing the skills they need to keep themselves safe.

Children need opportunities to explore the world on their own terms. Most adults I speak with immediately agree with this idea but are more hesitant when “their own terms” consist of “useless” activities like hitting things with a stick and throwing rocks in the woods.

Development Happens Through Doing

The fact of the matter is that the “useless” activities of childhood are critical for the later development of complex skills.

Through these movement experiments, children are constantly gathering information:

How much force do I need to lift this?
How do my body mechanics need to change for a bigger stick?
How do I keep my balance?
Is this bark sticky or rough?
Is this brittle and likely to break, or is it strong?

While many parents would feel more satisfied with their child playing some sort of “educational” game, it is often the skills practiced in unstructured free time that mature the neurological structures that support academic work.

Think about handwriting.

Writing requires precise control of the small muscles in the hands and fingers, as well as the muscles surrounding the eyes. They must keep their balance in a chair and stabilize their shoulder and elbow to maintain the endurance to write a longer piece. They must push into the paper, but not too hard, or they’ll tear it. They need these movements to remain consistent over a long period of time so that the letters stay the same size.

A child doesn't suddenly develop that ability at age six or seven. It grows out of thousands of earlier experiences involving movement, force, balance, coordination, and problem-solving.

Not to beat a dead horse (presumably with a stick), but by whacking a tree, a child is learning to integrate the information from thousands of sensory receptors and adjusting their body and actions accordingly.

Children learn by interacting with the real world—not just by being told about it.

Self-Regulation

One concern parents frequently have is safety.

What if they fall? What if they get hurt? What if they make a bad decision?

Those concerns are understandable. But when adults step back and observe, something interesting often happens.

Children naturally adjust their behavior based on their abilities.

When I have watched groups of children climb trees, the most coordinated and physically capable children tend to climb higher. The children who struggle with balance, strength, or coordination often stop much earlier on their own.

Their bodies are giving them information. Interfere and distract, and suddenly your input competes with the natural regulatory mechanisms protecting your child.

Failure

The goal of parenting is not to eliminate every risk. The goal is to help children become capable, independent adults.

Children need chances to fail. Not catastrophic failure. We are obligated to prevent kids from undue harm. While we strive to allow kids to make their own mistakes, we ought not let them make them in the middle of a busy street.

But there is normal childhood failure. Missing the jump. Dropping the stick. Trying something and realizing it didn't work.

These small setbacks teach resilience in a way that adults and apps never can.

Research shows that moderate stress and challenge help the brain learn. We are wired to avoid things that cause us pain.

So yes, Johnny will fall some of the time (not as often as you think), but he will. By falling, he will learn not to do the same thing again.

Most importantly, he will learn what he’s capable of overcoming.

That doesn't mean abandoning supervision or ignoring safety. It means recognizing that growth often happens in moments that look messy, unproductive, or even a little uncomfortable.

The confidence that leads to independence develops through experience. Ideal parenting often involves doing less.

A Challenge for Parents

Try giving your child a set time each day when you don't tell them what to do.

No instructions.

No corrections.

No organized activity.

Just space to explore, imagine, build, climb, dig, and create.

You might be surprised by what develops.

School Stress and the Importance of Culture

Thu, 11 Jun 2026 15:23:03 GMT

I was recently asked to speak to a school during a teacher workshop day. When the director first reached out, I assumed she wanted me to talk about ADHD, autism, suicide risk, or some other typical mental health topic. Instead, she asked a much broader question:

“Students are stressed. Teachers are stressed. What can we do about that?”

I remember thinking: that’s an enormous question.

Helping one struggling child and one set of parents is difficult enough. Trying to think about stress on the scale of an entire school — hundreds of students and dozens of adults — is a completely different challenge.

Still, I’ve spent much of the last twenty years thinking about schools. Schools are one of the biggest drivers of stress in children’s lives, and therefore one of the biggest drivers of my own business. Every year our admissions rise dramatically during the school year and fall off during the summer. That alone tells you something important.

So I started by asking a simple question: Why is school stressful?

The answers came quickly.

Students are asked to wake up early, often before their natural sleep rhythms allow. They are sent into large buildings filled with people they may or may not like. They sit through subjects they may or may not enjoy. They navigate friendships, competition, social hierarchies, rejection, embarrassment, pressure, and evaluation almost constantly.

And they still don’t get paid for it.

I joked during the talk that my own son recently asked why he doesn’t get paid for going to school, since it resembles a full-time job. Honestly, I didn’t have a particularly good answer.

Then I asked what stresses teachers.

The list turned out to be almost identical.

Teachers also wake up early. They also spend their days in large buildings filled with people they may or may not enjoy. They work within systems full of regulations, bureaucracy, deadlines, evaluations, and social conflict. They manage stress, exhaustion, and interpersonal tensions just like the students do.

The major difference is that teachers get paid, although often not enough.

Once we made the list, another realization became obvious:

Most of these stressors are not realistically modifiable.

Schools are not going to stop existing. Students are still going to have to interact with difficult people. There will still be deadlines, social pressures, evaluations, awkwardness, conflict, boredom, and stress.

So where should the focus go?

I would argue the single most important variable is culture.

Not curriculum, not breathing exercises, not motivational posters, but culture.

By culture, I mean the emotional and relational environment in which all of these stressful interactions occur.

When I first opened my own treatment program nearly twenty years ago, I asked my partner Joe what his plan was for running groups. I came from more traditional psychiatric settings where groups largely involved sitting in circles discussing CBT or DBT concepts for an hour at a time.

Joe gave a surprisingly simple answer.

“We’re going to establish a healthy group culture.”

At the time, I remember being a little skeptical. Eighteen years later, I think it is the single most important thing we do.

Our program treats children and teens with every imaginable combination of difficulties: depression, anxiety, autism, trauma, substance use, behavioral issues, court involvement, family conflict, school refusal, and more. The only way you can successfully place dozens of struggling adolescents in one closed environment is if there is a healthy culture holding the entire thing together. Without that, nothing else works very well.

Over the years, I’ve come to think healthy cultures share several important characteristics.

First, people feel they are on the same team working toward a common goal. They support each other, but they also challenge each other. Good cultures (just like good therapy, and good parenting) require both support and challenge simultaneously. People need to feel accepted and valued, but they also need to be expected to grow.

Second, conflict is viewed as inevitable and even healthy.

Human beings are different. That is not a flaw in the system — it is the system. Different personalities, perspectives, temperaments, and ideas are necessary for adaptation and growth. Healthy cultures understand that disagreement is not automatically dangerous. Conflict becomes something to work through rather than something to avoid at all costs.

Third, people assume goodwill before bad intent.

This is one of the most underrated aspects of healthy environments. In positive cultures, there is a general tendency to give one another the benefit of the doubt. People interpret ambiguous situations less defensively. That dramatically lowers tension and suspiciousness within groups.

Finally, healthy cultures acknowledge stress openly rather than pretending it does not exist.

Schools are stressful. Parenting is stressful. Teaching is stressful. Life is stressful. When stress is hidden or denied, it tends to emerge indirectly through irritability, withdrawal, gossip, conflict, and burnout.

A healthy culture allows people to say: “This is hard.”

And ideally, to maintain some humor about it as well.

One of the most powerful realizations I’ve had over the years is that relationships and group dynamics are often far more important than people realize.

I quoted two lines during the talk that capture this idea well.

The first: “You charge the hill because the person next to you does.”

Human beings will endure extraordinary hardship when they feel connected to a group with shared purpose, and will even charge a hill and straight into enemy fire.

The second was from Viktor Frankl: “Those who have a ‘why’ to live can bear almost any ‘how’.”

Meaning matters. Relationships matter. Shared identity matters.

Unfortunately, I think schools often underestimate how important explicit relationship education really is. We spend enormous amounts of time teaching reading, writing, mathematics, and science, all of which are important. But we largely assume children will somehow absorb social functioning automatically.

In reality, many of the most important adult skills are relational:

managing conflict
apologizing
tolerating discomfort
handling rejection
communicating frustration
taking space appropriately
resolving disagreements
functioning while stressed

These are not secondary life skills. They are foundational ones.

At our program, we make this explicit through what we call the Behavioral Guidelines, a one-page social code we’ve used for nearly two decades. Many of the rules sound almost painfully obvious:

greet people respectfully
acknowledge effort
apologize for offenses
communicate conflict directly
participate in resolution

The difficulty is not understanding these principles intellectually. The difficulty is practicing them consistently when people are tired, stressed, angry, anxious, embarrassed, or overwhelmed.

That is what culture really is: repeated relational habits practiced over time.

Schools face enormous challenges in maintaining healthy cultures, especially as they grow larger. Human beings simply function differently in smaller groups. Once groups become too large, people become less connected, less accountable, and less known to one another.

This is one reason I strongly believe schools should intentionally create smaller relational communities within larger systems whenever possible. Smaller groups create stronger connections, better communication, and healthier accountability.

I also believe schools benefit enormously from mixing students across ages and backgrounds rather than sorting everyone into rigid categories. Real life is heterogeneous. Children learn from differences, not just similarities.

One of the great mistakes I believe made by many mental health programs is over-separating people by diagnosis, age, or problem type. In reality, most human struggles are variations of the same developmental challenges: anxiety, identity, belonging, independence, competence, and relationships.

At the end of the talk, I emphasized one final point.

Adults in schools are not merely instructors. Whether they like it or not, they are role models and parental surrogates. Students watch how adults handle stress, disagreement, frustration, exhaustion, and conflict. Adults set the emotional tone whether intentionally or unintentionally.

Healthy cultures therefore cannot simply be demanded from students. They must be modeled by adults.

Ultimately, I do not think there is a simple solution to school stress. Complex problems rarely have simple solutions. But I do think culture is one of the most neglected and powerful variables in education.

A healthy culture does not eliminate stress, but it makes managing stress a team effort.

Functioning Better vs Feeling Better

Thu, 11 Jun 2026 14:19:06 GMT

One of the most important distinctions I’ve learned both as a psychiatrist and as a parent is the difference between feeling better and functioning better.

The two often overlap. When people function better, they frequently do feel better over time. But the two are not identical, and confusing them can create problems both in parenting and in mental health treatment.

A phrase I often return to is this: We are not in the feeling-better business. We are in the functioning better business.

That may sound harsh at first, especially in a culture that places enormous emphasis on emotional comfort and validation. Feelings matter. Of course they matter. We all want our children to feel happy, safe, confident, and loved. It hurts to watch people we care about struggle emotionally. As parents, therapists, and psychiatrists, there is a very natural urge to rush in and relieve discomfort.

But growth and discomfort are often inseparable.

Many of the experiences that ultimately help people become more capable, independent, and resilient initially feel worse, not better.

A teenager who is socially anxious may feel better staying home and avoiding uncomfortable situations. A child who falls off a bike may feel better putting the bike away for six months. A student who misses an appointment may feel better if a parent calls and fixes the problem for them.

In all of those situations, feeling better in the short term may interfere with functioning better in the long term.

One example I see frequently involves substance use. Imagine a seventeen-year-old girl who comes into treatment depressed, overwhelmed, struggling socially, and smoking marijuana throughout the day. Many teenagers will honestly tell you that marijuana helps them. In some ways, they are absolutely right. Substances often do make people feel better temporarily. That is precisely why they are appealing.

The problem is not that feeling better is bad. The problem is when the strategy used to feel better begins interfering with life itself. Smoking throughout the day may help someone escape stress temporarily, but it also interferes with memory, motivation, sleep, athletics, relationships, and eventually independence. The short-term emotional relief comes at the expense of long-term functioning.

Good treatment therefore often involves helping people tolerate discomfort while learning healthier ways to function.

Parenting works similarly.

One of the most common mistakes parents make is confusing helping with rescuing. A sixteen-year-old oversleeps and misses a dentist appointment. The parent feels tempted to call the office, smooth things over, perhaps even invent an excuse. In the short term, everyone feels better. The awkwardness disappears. The child avoids anxiety and embarrassment.

But something important is lost in the process.

The child loses the opportunity to:

take responsibility
tolerate discomfort
learn practical skills
manage consequences
become more independent

Parents understandably want to protect children from distress. The difficulty is that growth often requires manageable amounts of distress.

This is why I often say that good parenting and good therapy both require support and challenge.

Support matters enormously. Validation matters enormously. People need empathy. They need to feel understood and emotionally understood. “Toughen up” alone may not cut it for a child who is struggling.

But support alone is incomplete.

A therapist who only validates feelings without eventually moving toward action can accidentally reinforce helplessness. At some point the conversation has to shift from:

“That sounds really difficult.”

to :

“Okay. What are we going to do about it?”

One of my favorite therapists used to summarize this idea very simply:

“Yeah, that’s really hard. But you still have to brush your teeth.”

I’ve always liked that line because it captures both halves of the equation. Compassion and expectation. Empathy and responsibility.

A similar dynamic occurs when teaching a child to ride a bike. A child falls, scrapes a knee, and becomes frightened. A good parent comforts the child. But eventually the question becomes whether or not the child gets back on the bike.

Avoidance usually feels better immediately. Confronting fear usually feels worse initially. But confidence develops through experience, not avoidance. Children gradually learn that anxiety itself is not dangerous and that they are capable of functioning even while anxious.

That lesson is critical.

Many older adolescents and young adults struggle not because they have never felt anxious, but because they have never learned they can function while anxious.

Modern culture has become much better at discussing feelings, validating emotions, and recognizing mental health struggles. In many ways, that is genuine progress. Previous generations often ignored or dismissed emotional suffering altogether.

At the same time, I think the pendulum has swung somewhat too far toward emotional comfort and away from challenge, responsibility, and resilience. There is a difference between supporting someone emotionally and removing every discomfort from their path.

Ultimately, the goal of parenting, therapy, and psychiatric treatment is not to help people feel good in the moment. The goal is to help them become more capable of living life independently and effectively over time.

However… functioning better is usually what creates the deepest and most sustainable form of wellbeing anyway!

Functioning better is not a guarantee of happiness. Life is too complicated for that. But over the long term, functioning better gives people the best chance of building meaningful relationships, managing adversity, and creating lives that are stable, purposeful, and fulfilling.

The Goal of Parenting

Thu, 11 Jun 2026 14:13:55 GMT

The lawyer Clarence Darrow once said: “The first half of our lives is ruined by our parents, the second half by our children.”

I’ve always liked that quote. Partly because it’s funny, but also because there’s truth in it. Much of my professional life has involved sitting with teenagers and their parents trying to make life a little more tolerable for both of them. I’ve done that work for about twenty years now. I’ve learned even more from being a parent myself.

One thing parenting teaches very quickly is humility. It also teaches the importance of perspective and a sense of humor. Parenting (done right) is the hardest thing most people will ever do, and much of the conflict between parents and children comes from the fact that the aim of the job itself is easily forgotten .

Parents spend enormous amounts of time wondering:

how protective they should be
how strict they should be
how emotionally available they should be
how much freedom they should allow

But fewer stop to ask a more basic question: What exactly is the goal?

The best answer I’ve heard came from my own father, who was also a psychiatrist.

He used to say: “The role of the parent is to become obsolete.”

In other words, the job is to raise a child who eventually no longer needs you. The goal is their independence. That may sound obvious, but much of parenting becomes clearer once viewed through that lens.

Children are engaged in a gradual process of separating from their parents and becoming independent human beings. Psychologically, this process is often referred to as individuation. It begins very early and continues throughout adolescence and early adulthood. And it is inherently difficult for both parties.

Children push for greater independence. Parents worry that independence is arriving too quickly. Much of the tension between parents and children is really a disagreement about rate. Some children, by temperament, are naturally bold and independent. Others are cautious, anxious, and slower to separate. Parents vary as well. Some are comfortable allowing risk and autonomy. Others are far more protective and supervisory.

Neither side is entirely wrong. Good parenting requires a balance.

One important principle is: Maximum support with minimum interference.

Support should be abundant: love, encouragement, emotional availability, support, and protection from serious harm.

But support is not the same thing as constant intervention. Children need room to explore, make mistakes, develop confidence, and learn through trial and error.

A parent who interferes too much, even with good intentions, can unintentionally communicate: “You are not capable of handling this yourself.”

At the same time, good parenting also requires both support and challenge. A child should feel deeply loved while also being pushed toward greater maturity, responsibility, resilience, and self-sufficiency. Support without challenge can lead to dependence and stagnation. Challenge without support leads to insecurity and disconnection.

The difficulty is that these distinctions are often hard to see while living through them. In the midst of parenting, normal developmental struggles can easily feel pathological or catastrophic. One of the most useful things my work has taught me is that there is a much wider range of normal adolescent behavior than most parents realize. Many of the conflicts that families experience are not signs that something has gone terribly wrong. They are simply part of the messy and often uncomfortable process of growing up.

When facing difficult parenting decisions, it can be helpful to step back and ask a simple question: “Am I helping my child become more independent, or more dependent?”

That does not mean abandoning children to fend for themselves. Nor does it mean protecting them from every frustration, disappointment, or risk. The goal is to remain deeply supportive while interfering only as much as truly necessary, and continually encouraging growth toward independence.

There is no perfect formula for this. Parenting is too complicated for that. But clarity about the goal helps orient the process.

A Case Against "Locking Up the Sharps"

Tue, 02 Nov 2021 17:15:00 GMT

"Should I Lock Up The Sharps?"

Given what we know about Sarah, it sounds like the cutting has been superficial, and she likely falls into the first category. But keep both those categories in mind, as I’ll return to them later.

Let’s say mom decides to go with the “lock-up-the-sharps” approach. She takes all the knives from the silverware drawer, the scissors from the desk in the office, and the shaving razors out of the bathroom. She puts them into a cabinet and locks it up. She only gives them to Sarah when she can supervise their use, and then promptly locks them up afterward again. Let’s also assume, for the sake of argument, that Sarah isn’t a great lockpick. She can’t use those sharp objects to cut herself again.

Less access to sharps equals less chance of cutting again, so the thinking goes. Pretty simple and straightforward. But there are a few problems with this conventional advice that I'd like to raise.

What about securing medications, firearms, and more?

Before we get too far, it's important to make a distinction between "locking up the sharps," and securing firearms and medications. These are two (fairly) common household items that parents also ask me about.

Securing medication in the homes of struggling teens is a different story, and I believe it has to be done . Medications are used for only two things: medical treatment, and intentional overdose. Medical treatment needs to be supervised by parent. Impulsive overdose, in my experience, is much more dangerous than impulsive cutting. And, I would hope I wouldn’t have to say this, but firearms should always be locked up .

A Few Potential Problems With "Locking Up The Sharps"

Now let’s look at some of the problems with the “lock-up-the-sharps” approach, which may not be so obvious:

It’s hard to lock up all of the sharp items at home.

Things that are sharp are everywhere in our daily lives, often hiding in plain sight. It's not just the obvious dangers like knives and razors; there are countless other sharp objects lurking around us. Consider pencils with freshly sharpened points, shards of glass from broken bottles, jagged edges of tin from broken cans, and the fine tips of pins that can easily prick the skin.

With so many potential hazards, it becomes a nearly impossible task to keep all of these sharp items out of someone like Sarah's hands, as they seem to be a constant presence in her environment. Each day presents new challenges in preventing accidents and ensuring her safety amidst this array of sharp objects.

It may set up (or worsen) a power struggle.

Many teenagers – and maybe Sarah is one of them -- like to fight. It’s part of what teenagers do. One can easily imagine the following scenario: mom locks up the sharps; Sarah brings home broken glass she found on the street; mom takes broken glass; Sarah brings in razor blade from pencil sharpener at school; mom takes razor blade; Sarah smuggles in scissors and hides them under her bed; mom starts conducting regular room searches; and so on.

The power struggle between Sarah and her mom isn’t just a pain in the butt. It’s going to get in the way of their relationship . It’s going to negatively impact the chance of any kind of cooperative effort to solve whatever the real because the two are getting distracted by a sharps war.

It gives the message that he/she can’t control their own actions.

Locking away sharps is essentially telling Sarah that she is incapable of managing her own behavior. Worse, it suggests to her that keeping from cutting is her mother’s responsibility, not her own. Sarah may tell her therapist later on that her recent cuts are mom’s fault because mom didn’t do a good enough job keeping her away from sharps. (That’s actually one I’ve heard before.) The message mom is inadvertently giving Sarah is that Sarah is too depressed, too anxious, too angry, too defiant, or otherwise incapable of managing her own behavior. Thus, mom needs to do it for her. This is a very common message that I see parents giving kids these days, and it is a big problem. You’ll see me refer to it in other posts.

In a way, in locking up sharps, Sarah’s mom is taking a shortcut. Whatever mom gains in terms of short-term reassurance, she may lose in terms of hindering Sarah’s long-term development, learning to do things for herself, individuation from her mother, and pursuit of independence. In other words, growing up. And though a single act such as locking up sharps may not be that big of a deal for Sarah’s development by itself, it’s usually part of a larger pattern of “interventionist parenting”. It’s the pattern that can be so problematic – and even damaging -- to Sarah’s development.

Locking up sharps at home gives a false sense of security.

This is the biggest problem of all.

Let’s say Sarah isn’t in the superficial cutting category, but actually trying to seriously injure or kill herself. Keeping her home and “locking up the sharps” is a particularly bad idea because mom feels reassured that Sarah is somehow safe because the knives and scissors are hidden away. It won’t take Sarah much creativity to think of another way to hurt herself, or worse.

If Sarah’s mom thinks that Sarah is suicidal, hell-bent on injuring herself, or otherwise “can’t control herself,” she needs to get Sarah to the Emergency Room ASAP. Why fool around? Mom can’t keep Sarah away from all sharps (or other means of hurting herself) at home, but the hospital certainly can. It’s what inpatient units are designed to do. In this instance, locking up the sharps is a half-measure that may be worse than doing nothing at all.

So will locking up the sharps protect Sarah, or your teen, from cutting themself again? I don’t know. But I think it’s important to consider the potential risks of both leaving sharps out as well as trying to lock them away.

Is Your Child Struggling With Their Mental Health?

You're not alone—and you don’t have to navigate this journey without support. At Direction Behavioral Health, we specialize in helping troubled children and teens work through emotional challenges with care, expertise, and compassion. Whether you’re unsure of the next step or ready to explore treatment options, our team is here to listen and guide you.

Reach out today to start the conversation. Together, we can create a path forward.

Psychosis: An Open Letter to Hollywood Producers

Tue, 19 Oct 2021 16:08:00 GMT

Dear Hollywood Producers:

I am writing to offer my services as a psychiatrist with nearly 20 years of experience working with both adults and kids. I think, hired as a consultant, I would be able to help you improve the quality of your movies and shows. I also believe that your increased revenue from a better product (which I can help produce) will more than cover my services. My rates are quite reasonable.

Allow me to be frank. Your depiction of mental illness and psychiatric disorders in films is pretty terrible.

To be fair, I’m not a film buff, and haven’t seen all the movies and shows. And there are a few psychiatric disorders that some actors have done extremely well. For example, Jesse Plemons (Todd) and Krysten Ritter (Jane) of Breaking Bad did great jobs in portraying sociopathy and heroin addiction, respectively. Please pass my kudos along to producer Vince Gilligan for his casting. Some actors have convincingly played autism and narcissistic personality disorder as well (though I’m not sure that second one is coincidence).

But you really, really need help with the vast majority of conditions. Can’t we have one – just one! – movie that accurately portrays bipolar disorder? Or depression? Or schizophrenia? It doesn’t have to be a main character, nor the focus of the story. A realistic portrayal would not only make for a more powerful film, but it also would be a step toward dispelling some of the myths about mental illness and misconceptions of the general public. Now that would be a truly worthy cause!

I recently conducted a Google search in an effort to find films that accurately portray psychiatric conditions, and have assembled a short list. Several I have not seen, but I must say that I’m not optimistic. I am trying to keep an open mind, however. I hope in the upcoming weeks to review some of these movies and offer you some “constructive feedback”.

To give you a head start, and because I feel urgency to begin somewhere, let’s talk about the terms psychosis and psychotic. It drives me nuts, if you’ll pardon the expression, to see the terms thrown around so willy-nilly in movies. I also feel it does grave disservice to the public large in perpetuating misunderstanding about this condition.

Permit me to make a few recommendations here.

A Short Primer on Psychosis

What is “psychosis,” or the state of being “psychotic”?

A textbook definition of psychosis is “impaired reality testing,” which basically means you can’t tell what’s real and what’s not.
There are really only two ways the brain can’t tell what’s real from what’s not. The first is by the brain’s senses not working right (i.e., having hallucinations ), and the second is by the brain’s thinking not working right (i.e., having delusions ).
In general terms, if you do not have hallucinations or delusions , you are not psychotic.

Recommendation #1: stop using the terms “psychotic” and “psychosis” incorrectly.

What is a hallucination ?

It’s seeing or hearing (or theoretically smelling, tasting, or feeling) something that isn’t there.
Everybody thinks of visual hallucinations, or “seeing things,” when they think of mental illness. Far, far more common is “hearing things,” or auditory hallucinations.
Auditory hallucinations usually take the form of hearing voices . Most often these voices say nasty things about a psychotic person or tell the person to hurt or kill themselves. There are other things that psychotic people hear, but let’s keep it simple for now.
Visual hallucinations are uncommon in psychiatric illness. They occur much more often in medical illnesses and conditions. Some examples include being delirious from a high fever, having a neurological disorder like Alzheimer’s disease, or being intoxicated by illicit drugs.

Recommendation #2: let’s see more hearing things, less seeing things in your films.

What is a delusion ?

It’s a “fixed, false belief.” That means you believe that something is true (usually something extremely unlikely), and don’t change your opinion no matter how much evidence to the contrary you are presented with.
The most common kind of delusion is paranoia , or believing people are after you in some way. It might be the CIA, police, or your neighbors. You might think people are following you, stealing from you, playing tricks on you, or trying to kill you.
There are other types of delusions as well. Some are “grandiose,” like believing you are the second coming of Jesus Christ sent to save the world. Some are “somatic,” like believing your insides are rotting. Some are “bizarre,” like believing another person is living in your eyeball. Yes, that’s one I’ve personally seen.

Recommendation #3: use the term “delusional” correctly, and, if in doubt, stick to paranoia.

What causes psychosis?

Psychosis always happens for a reason. You don’t just become psychotic without other symptoms. (A rare exception is “delusional disorder,” but don’t worry about that for now).
You don’t have to be schizophrenic to be psychotic. Folks with bipolar disorder and even bad depression can hear voices or have delusions as well. Some neurological conditions, like Alzheimer’s Disease, also cause psychosis.
It’s very rare for young kids to be psychotic, because schizophrenia, bipolar disorder, and depression don’t fully develop until later in life. Although you may see other symptoms of these disorders earlier, you rarely see true psychotic symptoms until the late teens, at the earliest.

Recommendation #4: quit having people be psychotic for no reason.

What is psychosis NOT?

Psychosis is not “acting all crazy” or doing irrational things. In fact, it has nothing to do with behavior. It has everything to do with sensing and thinking. Remember, if you don’t have hallucinations or delusions, you aren’t psychotic.
A huge pet peeve of mine is the notion of “psychotic killers” in movies, shows, and books. Very few killers in real life are psychotic. They don’t hear voices or have delusions. Usually, they are angry or sadistic people who don’t care about others. They may be psychopaths, which are basically people with zero empathy. It’s like being a sociopath but more extreme. But psychopath and psychotic are two entirely different kettles of fish.

Recommendation #5: don’t call people psychotic unless they have hallucinations or delusions.

End of lesson.

I’m here to help. Together, I think we can really make some progress in more accurate portrayal of psychiatric conditions on the big screen, and at the same time improve the public’s understanding of psychiatric conditions. Feel free to contact me by email if you’d like to talk more about our potential partnership. In the meantime, I’ll be at home watching some movies.

Sincerely,

Duncan Gill, MD

Call Me Al: My Child Won’t Go to Therapy!

Thu, 07 Oct 2021 15:51:00 GMT

Direction Counselor: “The police are on their way.”

Words you never want to hear, particularly when you are taking care of kids.

“He didn’t want to come into Direction, mom told him he had to. He jumped out of the car, ran around the parking lot, then up into a tree.”

The really strange part is that I was literally writing this post about whether or not you should “make” your child go to therapy, when a counselor interrupted me with this information. When the boy settled down, the two came up to my office. I ended up talking about exactly what I was writing in this post. The two walked out after our discussion, mother quite understandably disappointed and son just happy to be going home. I hope he returns someday soon – he could use the help.

Let’s back up. When kids come in for their first interview at Direction, they often don’t want to be here. I’ve developed a little bit of a sales pitch for this very situation (which as you might guess happens a lot). It’s not that I want to trick kids into coming to the program, or promise them it will be something that it’s not, or just admit them for the sake of raising our census (there are plenty of other kids who need our services). It’s just that kids come in naturally resistant to joining a program like ours. Kids are understandably anxious; we are asking them both to share very personal information with adults they’ve never met, and to join a bunch of other kids they don’t know. The fact that they have often had mediocre (or worse) experiences in the past with therapy doesn’t help. So I just want to counterbalance those prejudices a little bit.

Let’s say a child -- call him “Al” -- is balking at coming to our program. I tell Al this a place kids like to be, that it’s very unlike school, and that many kids who hate the idea initially don’t want to leave the program when their time is up. These are all true statements. I tell him it might be worth a try for a day or two just to see what it’s like. Maybe Al thinks his parents are just excessively worried about him, and his problems really aren’t all that big. I tell Al we’d be happy to let his parents know that we agree with his self-assessment if that’s what it looks like to us once we get to know him. Maybe it’s worth Al’s time -- his spending a few days with us -- to appease his parents and get our stamp of approval.

Sometimes my spiel works, sometimes it doesn’t. If it doesn’t, the conversation might go like this:

Al: “Yeah, everyone seems nice here, but I don’t think it’s for me.”

And… that’s my cue to back off.

Me: “Gotcha. Well, you can talk it over with your parents then. We certainly aren’t going to try to force you to come. If you change your mind at some point, we’d love to have you here.”

Al talks with his father for a few minutes and Al’s dad enters the room.

Al’s Dad: “My kid says he doesn’t want to come. What should I do now???”

A perfectly reasonable question.

Well, what I can tell dad is that “forcing” therapy never works. It just doesn’t. If we don’t have Al’s buy-in -- or at least a willingness to give us a chance -- we have nothing. It reminds me of the old joke:

Question: How many psychiatrists does it take to change a lightbulb?

Answer: Just one, but the lightbulb has to have a sincere desire to change.

I absolutely recommend Al’s dad encourage him to “give it a try.” Al has really nothing to lose, and potentially a lot to gain. But once dad gets to the point where he is starting to plead with or threaten Al, it’s time to back off.

Not only will Al not benefit from therapy that he is unwilling to engage in, but the experience will be counterproductive to the relationship between Al and his dad as a whole. Al will become increasingly resentful at his dad . He will become more and more resistant, and possibly openly defiant. Al’s dad, on the other hand, will become increasingly desperate and frustrated. The two will be locked in an escalating power struggle (which may well be what brought Al to the office in the first place!). This is never productive.

What I do recommend to Al’s dad is that he attend our Parenting Group. And I don’t offer it as a sort of “consolation prize”. Regardless of whether he finds our particular group helpful or not (and I hope he does), Al’s dad is going to have to shift his focus away from Al and to the one person he does have control over: himself. His son is essentially saying “thanks, but no thanks.” That doesn’t mean Al’s dad has to say that too. Al’s dad is going to continue to be faced with the challenges of raising a son who is struggling, and perhaps we can help him there.

Al’s dad will need to deal with all kinds of decisions. Should Al go to school? Should he be allowed to see his friends? Should he be allowed to stay in bed all day? Should he be brought to the emergency room? Should dad call the cops if Al acts out?

In our case example, Al is saying he has got everything under control, neither wants nor needs therapy, and should be left alone, thank you very much. He might be right for all we know. Sometimes we parents overestimate the magnitude of our children’s problems. Sometimes kids outgrow their problems or get tired of their bad habits causing them grief. Sometimes hormones and moods settle down.

On the other hand, Al might not have it all under control. If that’s the case, it’s important Al’s dad not get in the way of his son’s coming to this conclusion himself. That means avoiding becoming overprotective or indulgent of his son’s potentially bad habits. It means not making excuses for his son, or being swayed by his son’s own excuses that he “can’t” control his behavior because he is too anxious, too angry, too depressed. This is a very common trap parents fall into in my experience, and it prolongs the problem. In fact, it deserves a separate post. I’ll get to that at some point.

The key here is that ultimately Al’s getting better is up to him, not his father. The fact that we don’t have control of all our children’s decisions can be a frustrating and disappointing realization to us parents. Particularly as kids get older. But, perhaps in an unexpected way, this realization can also be liberating to us as well. In the end, it’s not up to us, it’s up to them. It places responsibility squarely on the shoulders of our children, which is where it should be. After all, we aren’t going to be there forever for them, scrutinizing and intervening in their every decision.

In Al’s case, we are hoping for one of two outcomes in this situation. The first and best is that Al’s son solves his own problems or outgrows them. This is of course preferable to his enlisting the help of a therapist at all. The next best outcome is that things don’t improve, Al realizes that he could use the help, and ultimately accepts it.

Hopefully, the problem is resolved either way sooner rather than later. Anything that delays such a resolution – such as the power struggle of “making” Al go to therapy, or overprotecting and overindulging Al if he chooses not to go – just gets in the way. It prolongs the problem.

So those are my thoughts on the subject. The boy I referred to in the beginning of this post quite literally climbed up a tree to avoid going to therapy. It’s fair to say therapy just isn’t going to work for him right now, and it is counterproductive to try to force the issue. Best case is he pulls things together on his own, though I must admit that right now I’m doubtful on that score.

Second best case is that he shows up at our door within the next few weeks with a willingness – however grudgingly – to give treatment a try. That wouldn’t surprise me at all. And then we have something to work with.

Johnny: a DSM Diagnosis Dilemma

Wed, 29 Sep 2021 17:55:00 GMT

Mom: “Johnny has been looking depressed at home and stays in his room. He doesn’t do his schoolwork. He sometimes has panic attacks and either can’t or won’t go to school – I can’t really tell

which. He also has a really bad attitude.”

“Oh, and he’s been diagnosed with Major Depression, Panic Disorder, ADHD, and Oppositional Defiant Disorder. The doctor thinks he might be developing borderline personality disorder too.”

Uh-oh.

Sitting in my office is a well-meaning, anxious mother who is truly worried about her son. Next to her is Johnny, who looks angry and like he’d rather be sitting in a dentist’s chair.

Me: “Okay, Mrs. Smith. Does Johnny have a therapist?”

Mom: “Well, he had one, but he refused to go back after one meeting. He’s had a few before that but never seemed to connect with them.”

Me: “Does he take any medications?”

Mom: “Yes, I forgot the list, but he’s on four of them.”

Me, to Johnny: “You think the meds help you at all?”

Johnny: “Nope.”

Okay, we are running into “DSM Laundry List Syndrome”.

The problem isn’t so much the list of five diagnoses (which is overwhelming in and of itself), but the fact the mom believes that these five diagnoses mean more than they do. She thinks – and probably has been led to think – that this list of labels contains all the critical information we need to solve Johnny’s problems.

If Johnny has five diagnoses, does it mean that Johnny needs five different types of treatment? Five different medications? Five different types of therapy? Does a list of five diagnoses mean that Johnny is five times as impaired than if he had just one diagnosis? At the very least, in this particular case, a list of five diagnoses makes Johnny five times as angry with his mother and five times less likely to talk to therapists. Which ends up making my job more difficult.

Let’s get some context here. The DSM, or Diagnostic Statistical Manual, is considered by many (importantly, including insurance companies) to be the “bible” of psychiatric diagnosis. In the DSM you will find names and codes for all the possible diagnoses from Antisocial Personality Disorder to Voyeurism. All of Johnny’s current diagnoses are in there. The DSM diagnostic criteria consist of a series of checkboxes for various symptoms. Check enough of the boxes, and you qualify for a given diagnosis.

The DSM has pluses and minuses. On the plus side, it can be viewed as a valiant attempt to establish a common language for clinicians. The idea is to standardize diagnostic criteria so treatment providers are using the same words to describe the same things, rather than everyone having his or her own definition for different psychiatric conditions. You need to have some kind of standardization, particularly if you are going to conduct research. You have to be able to decide, for example, who has bipolar disorder and qualifies for the study, and who doesn’t. And research has been critical to developing fantastic new treatments for psychiatric conditions. So, to that extent, we need a DSM, or something like it.

Now for the minuses. The diagnostic criteria are decided by committee. A group of psychiatrists gets together and debates what should be a diagnosis, what shouldn’t, and what the criteria for each should be. Clinicians have varying degrees of confidence, shall we say, as to how good a job the DSM does at describing any given diagnosis. In my opinion, it does a good job for some diagnoses and a not so-good-job for others. A lot of folks also think the “checkbox” approach is quite limiting. I agree. By the way, the DSM goes through changes every few years, and some diagnoses disappear and new ones magically materialize based the current zeitgeist of psychiatry.

It’s important to realize that – as of 2021 – we have exactly zero blood tests and exactly zero brain scans that can accurately determine psychiatric diagnosis. And “standardized tests” and rating scales are only as good as the clinicians interpreting them. Suffice it to say the brain is really, really complicated. The best way to make a diagnosis is to sit down with patients and talk to them.

Let’s get back to Johnny. His list of five DSM diagnoses doesn’t tell us anything about his circumstances. Nothing about his temperament, home life, parenting, or stage of maturity. These factors – let’s call them “developmental” factors – might account for a lot of Johnny’s problems, or maybe even all of them. DSM diagnoses are an attempt to standardize, which is good for a lot of conditions, but developmental factors don’t standardize well, and just end up being omitted altogether.

So, it’s possible Johnny has a real, biological “Major Depressive Disorder,” but it’s also possible his parents are going through a divorce and he’s just having a rough time.

The DSM checkbox approach can also be taken too literally. Sure, Johnny technically may “qualify” for all five diagnoses, but is that the most useful way to look at things? Does this mean he truly has five different conditions? Or is he simply depressed, gets anxious and angry when he has to go to school, and doesn’t pay attention in school because he’s got too much else on his mind?

Don’t even get me started on “Oppositional Defiant Disorder”….

Sorry, I can’t help myself. I think Oppositional Defiant Disorder is a prime example of the DSM’s going off track. Kids are oppositional for a whole bunch of reasons. They get tired of being told what to do, they have unreasonable adult figures in their lives, they are immature, they are trying to demonstrate to their friends or parents or themselves that they are independent and don’t take crap from anybody. Being oppositional is not a “disorder”. It’s an adjective.

Thanks for indulging me there.

All this is a long way of saying sure, DSM diagnoses have some utility, but my goodness we need to understand their limitations. Excessive reliance on them sometimes overcomplicates relatively simple problems, and sometimes it misses the boat on developmental problems entirely.

Back to Johnny.

Me: “Okay, Mrs. Smith, how about we start from the beginning?”

All In The Family: Why I Do What I Do

Wed, 29 Sep 2021 16:24:00 GMT

My father has a thing for guitars and banjos. Like, abnormally so. At last count, he had well over a hundred hard-shell cases taking up space in the attic, his home office, the living room, and honestly pretty much every other room in the house. Any remaining space at home seems to be occupied by uninstalled doors and fireplaces, which for some inexplicable reason he also collects. It drives my mother absolutely crazy.

He seems to have unlimited energy, and his mind is always going a mile a minute. Throughout his life, he has worked about three full-time jobs at a time. (He recently “semi-retired,” cutting down to the equivalent of one full-time job.) He personally built our house from the ground up, adding rooms left and right, sometimes entire wings. My mother (she really is a saint) has given the rooms creative names such as “The Giraffe Room,” “The Omni,” and “The Purgatory”. The last one was so named because it hasn’t been finished, nor will it likely ever be. My father is great at starting projects, but less great at finishing them.

Bipolar disorder runs heavily in my family, and though he doesn’t meet the “classic” bipolar criteria, it doesn’t take a Sigmund Freud to guess he’s got an undiagnosed, chronically hypomanic bipolar version. He’s actually written several books on bipolar disorder.

Oh, and he’s a psychiatrist. I guess that was a round-about way of getting to that point, but the preamble seemed relevant to me for some reason. He loves what he does and – being articulate and persuasive with words – managed to talk my best friend growing up into becoming a psychiatrist as well.

My (bipolar) aunt once said, “Dave, you make your bipolar work for you.”

My father isn’t the only psychiatrist in the family. His own father and uncle were psychiatrists, one brother a psychiatrist, and the other a therapist. His lone sister escaped our “family gift and family curse” to become an artist. His daughter, my sister, is also a psychiatrist.

Genetically, it would seem I was doomed from the beginning. And, despite all my efforts in medical school to beat the odds and become an emergency room doc, I finally gave in. I realized that rejecting a career that seemed such a good fit for me just for the sake of being different wasn’t a good enough reason. That’s what a psychiatrist would say, anyway. At least I became a child psychiatrist, a novelty in the family, and maybe that counts for something.

Psychiatry is a really a great career, as long as you can get past that pause in the conversation when you tell people what you do for a living. It’s sort of like telling people you work on septic systems or raise llamas. It’s a pause of equal parts horror and fascination.

Once they regain their words, their most common response is: “Wow, I could never do that.”

I forget that not everyone likes working with teens, or even likes teens in general. I think it’s great. I can be my normal, slightly hyperactive, inattentive self. I can rock back in my chair, make jokes, laugh, and goof around with kids. I can talk about music or sports or the latest Warzone loadout with them. I can even swear. Kids do their best to keep me current with the latest kid slang, though even so I always seem to be lagging about 10 years behind. Heck, I even get paid to play the occasional frisbee or foosball game. Life is good!

But most of all, maybe because of my inner teenager, I identify and sympathize with these kids. I see them struggle with the trials and tribulations of adolescence when school is a prison, parents are tyrants, breakups are catastrophes, and the world is a big scary place. It is a great challenge to get them to accept even a tiny bit of perspective from me, someone who has made it to the other side, someone who has made it to adulthood. And any parent can tell you this is no easy task, as kids generally aren’t interested in and / or can’t hear and / or don’t want to hear what adults have to say about anything. This challenge requires first gaining their interest, then their trust, and then their respect as a sympathetic, non-judgmental adult figure. It’s doable in almost every case. This challenge – even more so than the frisbee and foosball – is my favorite part of the job.

So being a child psychiatrist suits me on many levels. I feel lucky to be one of those people who doesn’t dread going to work or coming home from vacations.

I can hear my aunt in my head saying: “Dunc, you make your inner teenager work for you.”

People sometimes ask me if being a child psychiatrist makes you a better parent. It’s a good question, and I’m not sure of the answer. I think it does help in that you get to see so many struggling kids that you tend panic less when your children act out or otherwise hit bumps in the road. I’ve been asked for reassurance by many friends and family about their own children, and my usual conclusion is that they are suffering from a normal variant of adolescence. I have to say, though, it sure is different when it is your own kid. One of my favorite mentors when I was in residency – one of those guys who you think was just a master at what he did – admitted that he had to stop practicing psychiatry entirely for the period that his daughter was a teenager.

I’m not sure if the three-generation psychiatry Gill-line ends with me, but I hope not. Given half a chance, I’m sure my father can talk at least one of my kids into going into the family business….