Every parent’s nightmare

All good parents – and most not-very-good-at-it parents – want what is good for their children. They would like them to grow up happy and healthy, to have a comfortable life, stay out of jail, etc. A few grandchildren and regular calls and visits would be nice.
Often unspoken, but definitely there, is the desire that their child not be what they might call “crazy.” It’s not my word – I’d use depressed or anxious, or having a psychotic episode – but for parents, one of the greatest fears of all is that their child grows up to be mentally ill, with hallucinations and delusional beliefs – to be out of touch with reality, to be, in short, psychotic.
Psychotic doesn’t mean “violent and crazy,” as it is so often misused. It means to be out of touch with reality, often with some sort of hallucination (hearing voices, seeing things that aren’t there, or some other sensory misinformation) and/or delusional beliefs (paranoia, which may mean being persecuted or it may mean an unrealistic arrogance, belief in one’s special powers, or that one is in fact someone of great power and importance).
And, it turns out, psychotic symptoms are a risk factor for two common substances in the lives of young people: methylphenidate, a commonly prescribed drug for ADD/ADHD, and cannabis.
The research on methylphenidate has been ongoing, in some cases for decades, and while you cannot do experiments to “prove it” (who would volunteer to try to have their child rendered psychotic just to see about a drug’s effects?), researchers scour multiple studies following up on children and teens prescribed methylphenidate, and find that 1 to 2.5% develop psychotic symptoms. That’s up to more than one in 50. The latest meta-analysis was published this summer in the Scandinavian Journal of Child Psychiatry and Psychology, using multiple studies with over 77,000 young people in all.
The link between cannabis and later psychotic symptoms, as well as anxiety, for young people has been known for years, but often studies began in the mid- to late-teen years and it was difficult to determine if those who were prone to mental disturbances were more attracted to cannabis than healthy teens, or if otherwise healthy teens were developing psychosis as a result of cannabis use. With studies beginning earlier – in 7th grade – researchers feel confident asserting there is an increased risk for psychotic symptoms within a year after a teen begins using cannabis. This is for all teens, not just those with family histories of psychotic illnesses such as schizophrenia.
What should parents and other caregivers do?
If your child is being treated with methylphenidate, work closely with the prescribing physician to monitor side effects, be honest about what you observe, and do not panic. Remember that counseling and neurofeedback, provided by experts, can help someone diagnosed with attention deficits develop skills and neurological adaptations to reduce symptoms. Seek a referral from your child’s physician.
In terms of illegal drug use…assume no “safe” amount of an illegal substance. The fact that many states have legalized or decriminalized marijuana has misled many people to believe it is “safe.” It is not. The American Medical Association and the American Psychiatric Association both have published strong positions warning about the use of marijuana.
Parents and caregivers also need to be mindful that the drugs used for ADD/ADHD, and methylphenidate as an illegal substance, are popularly misused, sold, or shared among young people. According to studies published as recently as last autumn, 5 to 10% of high school students and 5 to 35% of college students use, or have used, prescriptions for ADD/ADHD illegally as “smart” or “study” drugs. This may be regular use, or may be occasional to get through end-of-term crunches with minimal sleep. Side effects include sleeplessness, agitation, anxiety, dizziness, headache, sweating, appetite loss, elevated blood pressure, and psychosis.
Be alert for subtle changes in behavior and do not be afraid to be assertive about this. Your child’s physical and mental health may depend upon it.

Go and Do, for Me and You

Verbs, like “go” and “do”
In a recent on-air segment, Jamie and I (he’s the afternoon radio talent for Spirit FM, the local Catholic radio station/Christian pop music station where I’ve been volunteering since 2009) were discussing various social protests. He had asked me how to handle the flood of social media, with people posting/re-posting/re-re-posting, and the pressure to have some sort of opinion/assert some stand on perpetually protesting celebrity.
I try, but don’t always succeed, in preferring action verbs. Like, “go” and “do.” I don’t much care for meetings. I don’t like sitting around talking about how we can help the homeless and severely mentally ill. I went and did (full time work, almost 5 years). Jesus didn’t say, sit around and have lots of committee meetings. He said, pretty much, Go… (He also had something to say about babbling on and on, so I will move along.) I would rather teach than talk about teaching, do art than sit around talking about art…you get the idea.
So my thoughts are, go and do. It would be far more helpful – if, for example, we are talking about the real and obvious pain in poor neighborhoods – to go and do. Mentor a kid. Be a Big Brother/Big Sister. Organize a community watch organization. Do pro bono work in your field. Provide free tutoring. Be a Guardian ad Litem. Etc., etc. Go and do. Standing around getting attention for taking a public position that costs nothing seems a little self-serving.
It reminds me of the time a woman I knew criticized me for failing to wear red on some arbitrary date publicly announced to be the day to wear red to support women’s heart health. The only woman whose heart I have much influence over is my own. I had already exercised, gone to church, had good conversation with my husband, eaten a healthy breakfast – in other words, it was 8 AM and I had done all I could for THIS woman’s heart health. Nothing I was going to do, besides pray and try to set a half-decent example, would help anyone else.
It also brings to mind the big test for reports of visions of the Blessed Virgin Mary. Such a report requires much evidence, but a primary benchmark requires that Mary points towards Jesus. There is no credibility if the reported vision does not direct people towards Jesus. Such an experience is not something from the Good side. It might be a well-intentioned, innocent delusion, but it is not Mary. Mary doesn’t showboat.
So…if terrible injustice moves you, go and do something concrete, specific and clearly helpful for one particular person. Keep the meme to yourself.
…and more on “Go” and “Do”
Teen and young adult mental health took a drastic, terrifying turn for the worse beginning in 2007 – and the stats keep worsening, especially since 2012. This, according to a lot of research, can be traced back to the smart phone, according to San Diego State University professor, researcher and author Jean Twenge. Her recent book, “iGen: Why Today’s Super-connected Kids are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood – and What that Means for the Rest of Us,” provides the results of not just her original research but meta-analysis of generations of data on the pattern of mental health and activity for youth.
It seems like constant connectivity has led to less “go” and “do” and more detachment and isolation. It’s a double-dose of negative: the ineluctable distance created by screen-based communication and a deficit of direct experiences. We were not designed to sit and click; we are made to go and do.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

Posts are for entertainment and not meant to be construed as treatment or professional recommendations. If you need mental health assistance, please contact a licensed professional in your area.

To Live Long, To Live Well: The Ongoing Research

Cognitive decline – dementia – Alzheimer’s disease – senility – to lose our independence, our memories, our minds – our “selves.” This is one of our greatest nightmares. But, what if this precipice – the thing people seem to fear worse than death – is almost entirely avoidable by changing how we live?

The Alzheimer’s Solution: by Dean Sherzai, MD, PhD and Ayesha Sherzai, MD (2017) asserts that this is indeed the case. You won’t find wishes, a few convenient anecdotes and flimsy, recent research. The doctors Sherzai tie together decades of substantive research from multiple, credible sources (including ongoing Blue Zones research) and their own research and medical practice. The result of this work: a straightforward and remarkably simple (albeit not easy) recipe for long, healthy mental functioning.

Unfortunately, it requires that we do stuff. Differently. In a lot of cases, way, way differently.

Here’s a synopsis:

They use the helpful and appropriate acronym NEURO: Nutrition, Exercise, Unwind, Restore, Optimize

Nutrition: quite specific nutritional guidance – recommending a largely vegetarian diet high in specific types of nutrients.

Exercise: not just a regular appointment at the running path or the gym, the research emphasizes activity throughout the day on a frequent basis.

Unwind: Managing stress healthfully and living with purpose.

Restore: Enough good quality sleep (this is a tough one for me). There is no substitute for sufficient sleep in terms of long-term brain health

Optimize: a lifetime process, and never too late to start: complex, creative, learning and doing. While the puzzles we encourage elders to do to keep their minds nimble are a small part, greater benefit comes from ongoing learning, complex tasks, mentoring/teaching and other activities that use multiple skills.

The book, published this past summer, includes interesting case studies, questionnaires and specific recommendations to make changes as needed on a case-by-case study. It’s helpful to remember that, all over the world, there are “Blue Zone” communities – places where most people live long, robust lives free of chronic diseases and dementia – where these lifestyle choices are just “normal,” not sacrifices. At least, I tell myself it’s helpful.

My challenge, which I share and dare towards you: do some investigating on this. If you’re intrepid – seek your physician’s guidance and take it from there. If you’re a little timid, hesitant or just plain skeptical, pick one piece that’s easy to do, get the medical OK, and go for it.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC


Posts are for entertainment and not meant to be construed as treatment or professional recommendations. If you need mental health assistance, please contact a licensed professional in your area.

When Media Lies Hurt: The Destructive Impact of Sloppy Journalism on Real People

(Originally published in USA Today Magazine, July 2016. A few updates were made for reposting to this blog)

It’s safe to say that most people have long since given up on the idea of unquestioning trust for the media. Walter Cronkite died in 2009. Despite vague mistrust, people are vulnerable to the effect that repeatedly hearing things has. Hearing something over and over engrains it in our brains, even if it’s not true. The repeated lie tends to rise to the top when a related topic comes up. This is one reason so many people believe that, for example, violent crime is up all over the country (it’s not) or that we know for sure exactly what schizophrenia is, or what it’s caused by (we don’t).

As a psychotherapist, I see the pain that sloppy journalism creates for real people on a regular basis. I don’t mean transient worry; I mean the possibility of a lifetime of unnecessary anguish inflicted upon people who believe that the information hurled at them by media must be based in truth.

Three examples will suffice to illustrate; you can no doubt generate plenty of examples of your own.

Media Misrepresentation: People considering suicide always give clues about their intention, and thus friends and family have an opportunity to see it coming and intervene.

According to A. Dadoly in the Harvard Health Newsletter (2011), professional estimates are that 30-80% of suicides are impulsive acts, with little or no planning beyond the immediacy of the moment. That means family members could usually not have read the signs, and could not possibly have intervened. Yet, most people believe, because they’ve been told repeatedly, that warning signs are just about always there and thus are tormented with guilt and self-reproach for failing to see something that was, tragically, probably not there.

Media Misrepresentation: Depression is a medical illness that is a lifelong condition. You’ll be on medication forever because there is something wrong with your brain.

The truth is, depression, or “major depressive disorder,” as it is currently labeled, is a construct. It is diagnosed off a checklist of symptoms. Meet enough of the symptoms for a two-week period of time and, bingo, you can be diagnosed, whether that sadness, poor sleep, lack of energy, poor concentration, etc., is due to grief because someone you love has died, or to some other life circumstance…or, perhaps, something medical. Some research indicates that most cases of depression will improve within 7 weeks whether you do anything to treat it or not. Plenty of evidence shows that lifestyle changes such as proper sleep, diet and exercise, plus social supports and a bit of emotional support via therapy, will create improvement in less time and leave you more resilient the next time life throws you a challenge (which, of course, it will). You can find a wealth of scientific research as well as specific steps to apply that research to real life in Stephen Ilardi, MD, Ph.D.’s wonderful 2009 book, The Depression Cure. There’s plenty of other research out there, of course, but for busy readers, Dr. Ilardi has done a masterful job of tying together many researchers’ work and working out a useful process.

Yet millions of people have been sold the lie that their symptoms are evidence of a brain disorder that requires lifelong medication. The medications change the brain, cause all sorts of unpleasant side effects, such as weight gain, loss of sexual interest and/or function, and general apathy towards others, and often cause terrible withdrawal symptoms. They also carry a risk for impulsive acts of self-harm, including suicide, and violence against others. Almost every adolescent and young adult mass killer in the US in the past couple of decades, with the exception of avowed Islamist terrorists, has been on one or more psychiatric drugs, including many antidepressants.

Do these medications help some people? Apparently so, according to them and their doctors. That does not, however, prove that everyone who is sad for more than two weeks has an incurable but manageable brain disease and is “mentally ill.”

Media Misrepresentation: Your gay son or daughter is going to burn in hell just because he/she is LGBT.

This lie is a criticism of many religions, and recently has been part of the background of a television show called “The Real O’Neals.” One part of the plot involves a gay young man whose supposedly Catholic mother is consumed with despair because “her religion teaches her that her son is going to burn in hell because he is gay.” That’s a paraphrase from interviews I’ve read with a star of the show. I have seen many families suffer under this belief. Parents are alienated from their children; children believe that their parents are condemning them; parents and children alike reject their faith. I will address this from my Catholic perspective; you can do the homework on your faith.

The Catholic Church has an international apostolate (a fancy term for an approved special ministry) called Courage, focused entirely on providing spiritual, emotional and social support for LGBT Catholics. Its intention is not to “make them straight,” but to help them live Catholic lives with the orientation they experience. The official Catechism of the Catholic Church isn’t exactly politically correct: like the psychiatrists of just one generation ago, it considers homosexual behavior disordered – but you could say Catholicism (and all orthodox Christianity) says about the same about any sexual activity outside of marriage.

However, the Catechism of the Catholic Church also says: (paragraph 2358):

The number of men and women who have deep-seated homosexual tendencies is not negligible…They must be accepted with respect, compassion and sensitivity. Every sign of unjust discrimination in their regard should be avoided. These persons are called to fulfill God’s will in their lives and, if they are Christians, to unite to the sacrifice of the Lord’s Cross the difficulties they may encounter… (that “uniting to the sacrifice of the Lord’s Cross, is of course, what all Catholics do when, faced with challenges, we talk about “offering it up” – this is not a unique imposition upon GLBT persons).

Paragraph 2359 ends with, “They can and should gradually and resolutely approach Christian perfection.” Hmmm. No ineluctable path to hell and damnation there.

One can, however, imagine the pain of a parent who imagines their child is immediately rejected by God. One wishes they were bold enough to seek right guidance.

Our Responsibility

It’s easy, of course, to blame the media. Journalists go to college and seem to take pride in getting the “real story,” or whatever they imagine they’re doing. So why don’t they do their homework? Why present the easy, available tale? Psychologically, they appear to indulge in confirmation bias: the tendency to seek out and focus on things that verify what they already “know.” We consumers of media need to check the facts.

Bad information creates pain and suffering. Don’t assume what you read is the whole truth. Do your research, and turn to people who might have access to information you don’t have. Someone’s peace of mind may be at stake.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Internet Gaming Disorder? Is that a thing?

Yes, it’s a thing.

Are you (or someone you love) hooked on internet gaming?

An excellent recent article on parenting in Real Simple, “Parenting Against the Internet,” cited a statistic that the average adolescent male spends 20 hours a week playing internet games, and the average adolescent female spends 10 hours a week.

The internet can be great: I can look up all sorts of research, read the news, check the weather, contact family and friends around the world, find obscure used books in a mom-and-pop used book store somewhere across the country…

But for some people, the something good turns into a real problem. The American Psychiatric Association, in its 2013 update on diagnoses, the DSM-5, named Internet Gaming Disorder as a “condition for further study,” rather than an official diagnosis with its own billing code. Tune in within a few years; no doubt, that will change.

Twenty hours a week is a lot of time to spend doing something that teaches little, if any, useful knowledge; isolates a person from contact with real people and real life; is sedentary; and creates a world that is not real but full of very real gratification in terms of the brain’s dopamine system. That’s the average; that means for some people, there’s little or none and for some, it’s the equivalent of a full-time job, absorbing time, energy and mental space that could be dedicated to learning real-life skills, creativity, and other parts of life. Please don’t bother emailing me with examples of games where prosocial behavior is rewarded or you have to know useful stuff to be successful; I know. I also know that at some point it’s unhealthy to live in an artificial land of make-believe, instead of taking that pro-social behavior and useful knowledge and using it to make the world, and yourself, better.

What are the warning signs of this disorder that warrants further expert study? Persistent preoccupation; withdrawal symptoms such as irritability when the games are taken away; tolerance (more time playing games as time goes by); unsuccessful attempts to control the amount of time playing (for example, promising to cut back now that school has begun and sliding right back into excess); losing interest in other activities; continued excessive use of games in spite of problems in relationships, job, school, etc.; lying about how much time is spent playing; using games to deal with other problems (the game is a drug to feel better at this point); jeopardizing or already lost significant relationship, job, educational or career opportunities because of involvement in playing internet games (American Psychiatric Association, 2013). Note that these are games – gambling on the internet is already an official diagnosis when carried too far.

Most people can easily see the degree to which these signs are awfully similar to what we would use to assess a problem with alcohol or drugs: preoccupied with drinking? Cranky or shaky when they can’t get their “fix?” Unable to cut back; getting behind in life in all sorts of areas; lying about how much is used…so why are parents apparently turning a blind eye to how much time their kids spend in this world?

Some theories:

  1. Some parents are as active in gaming as their children and have convinced themselves that those excessive hours are better than other things their child might do. Well, yeah; I suppose you could also argue that it’s better for your child to get drunk than to inject heroin, but that doesn’t make getting drunk a desirable behavior.
  2. Some parents are unaware. They do not realize what their kids are doing in their rooms, on their phones, half the night, or when they’re supposedly doing homework, or when they are in a college classroom, not paying attention.
  3. Some parents think it will be outgrown…although the social skills deficits these young addicts have will often interfere with their ability to successfully navigate college, trade schools and work.

Of course, it’s not just teens. There are adults who sometimes work full time, or part-time, and spent 30+ hours gaming each week. They tend to have marital problems, job problems, or both. Perhaps they have neither a relationship nor a job, but do have angry parents who want very much to be empty-nesters, any decade now.

Don’t think this applies to your child, or to you? Try cutting it off for a week. A week’s not that long. No exceptions. Notice what happens. If you’re afraid to even bring it up because you “don’t want to deal with it,” you have just told yourself something very powerful, and somewhat frightening, about your confidence as a parent and your child’s relationship with gaming.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.


Wrestling with OCD

If you have suffered with Obsessive Compulsive Disorder (OCD), or know someone who has, you are probably familiar with those distressing, intrusive thoughts that create so much anxiety. Traditional psychoanalysis used to focus on the content of those thoughts and seek to uncover the deep, buried wounds and wishes that led to these strange, seemingly alien notions. Thus the woman who was obsessed with the fear that her child would get hurt walking to school might be analyzed and advised that she seems to have a deep resentment against the child and all the responsibilities of motherhood and the worry is really an expression of an unconscious wish to be rid of the child. Talk about a guilt trip…!

Modern research and practice in treating OCD tends more towards the notion that everyone’s brain generates random and sometimes pretty crazy-sounding thoughts. Thus, the treatment is much less about wrestling with the particular content of the OCD thoughts and more about learning to compassionately notice that thought happening among all the other thoughts firing off like popcorn in the typical brain, use strategies to calm down the anxious physical reaction to the thought and refocus, gently and purposefully, on what one would rather think about at that moment in time. It stops becoming “Don’t think about X,” (try that: right now, I forbid you to think about pizza. Ha – how long did it take to imagine a pizza?). Instead, it becomes, “Yup, there’s that thought about X…and now I will take a deep breath and refocus on what I was doing/what’s going on right here and now.”

This is what mindfulness, stress management and cognitive-behavioral therapy can do, together, to help with OCD. The brain changes in response to choosing these behaviors, and the degree of physical distress decreases throughout the whole body.

If you are suffering with OCD, this kind of very well-researched approach may be what you need. Please contact a professional in your area if you think this might be helpful for you.

Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

Military Mental Health

It seems as if daily we are told how shamefully the military handles the problem of psychological distress and emotional pain for our men and women in uniform. In May, the USA Today newspaper empire asserted that the “Pentagon [is] perpetuating stigmas that hang over treatment, study finds.” (Zoroya, USA Today, May 6, 2016). The military is criticized because it takes mental health issues seriously enough to reconsider security clearances…unnecessarily “stigmatizing” those who have sought treatment.

This supposed stigmatization merits careful consideration. These include the depth and breadth of existing mental health services for active duty personnel and veterans; the conflicted American mindset on mental illness and emotional distress; and the logical outcome of this strange ambivalence.

A person not in the military or close to military personnel, may reasonably be under the carefully groomed media misimpression that the emotional well-being of our soldiers, sailors, airmen and marines is some sort of vague afterthought. Perhaps the general public is unaware that military mental health officers (people who are qualified to be licensed solo practitioners in the civilian world) are found in forward operating bases, combat outposts, and other deployment settings, providing critical incident debriefings, assessments, counseling, and referrals for more comprehensive care. When young men in harm’s way are despondent over a wife’s philandering, or are heartbroken over missing their child’s birth, the mental health officer is there. When there are incoming mortars, the mental health officer is there. When someone’s reaction to the weekly required malaria medication is extreme (malaria meds cause short-lived anxiety in about 1 in 10 people, and for some of that 10%, paranoia kicks in briefly, too), the mental health officer is the one who can figure out what’s going on and have the physician provide an alternative medication for the soldier – saving a military career from dissolving due to what looks like psychosis but is a transient medication side effect. In short, when crises occur, the “doc” or “shrink” or “combat stress lady” (quotes from military personnel) is there.

It is understandable that most civilians are unaware of mental health clinics on military bases, where military personnel and their families can receive counseling. Besides basic counseling services, mental health personnel provide services such as outreach before, during and after deployment, support while preparing for new babies, parent training, marriage counseling, couples’ retreat weekends, substance abuse education, and more. All these are part of the routine in military mental health clinics. Mental health officers are also able to veto a transfer if any member of the transferring family’s health or mental health needs cannot be adequately met at the new location. So…if Mom is being transferred to Base “A” and that area doesn’t have the specialized services that one child in the family needs, the transfer is nixed – possibly by a licensed clinical social worker at Lieutenant rank. The 2nd Lt. just overrode the entire command structure, in the military that is decried for not taking mental health needs seriously.

Then there are the VA system and the Vet Centers. Vet Centers are cousins of the VA. Unlike the VA, Vet Centers require only a DD 214 to provide free individual, couple or family therapy. It doesn’t have to be service-related…but if the problem seems to be service-related after all, the Vet Center personnel can help facilitate connection to the VA proper. These, too, are staffed by people licensed in their respective states as solo practitioners. There are no “not good enough to make it in private settings” amateurs serving in mental health positions.

Finally, there is the difference between benefits (think, Tricare, which is insurance for post-military service) versus service-connected health care (think, the VA system). A lot of veterans get that confused, and any of us who have tried to deal with health insurance and making sense of what is/is not covered, copays and coinsurance, and in and out of network…well, it’s understandable that almost anyone would find it confusing. Fortunately, the VA system and Tricare have professionals who do a lot of work (and get yelled at a lot) in trying to help people understand their benefits/insurance/service-connected health care, and connect them to the right services.

There are mental health services for military personnel and veterans. There could certainly be more, and the services available could be better marketed. In addition…there are stigmas.

Those stigmata comprise one more disgraceful example of too many Americans wanting to have their cake and eat it, too.

The regrettable medicalization of mental health has resulted in the mythology – happily embraced by many in the medical, pharmaceutical and professional-helper fields, as well as by many in the general public – that all mental disorder diagnoses are brain diseases. For example, many professionals will assure you that depression is strictly medical in nature; a brain disease, incurable but treatable by manipulating brain chemistry. Likewise, anxiety is (supposedly) purely a physical issue. People collect Social Security Disability, disability from their employers’ insurance, and other benefits, based upon having some sort of lifelong brain disease (according to psychiatry).

There are plenty of people eager to buy into this. We hear depression is epidemic (what else could we call something that apparently affects at least 20% of women and 10% of men each year, based on prescriptions for drugs?). Well, here is a recipe for depression:

  1. Maintain a sedentary lifestyle
  2. Eat a lot of junk food and assiduously avoid adequate portions of healthy foods
  3. Smoke cigarettes and/or abuse illegal or prescription drugs
  4. Drink more than one drink daily (females) or two drinks daily (males), or more than your physician recommends, given your particular health profile.
  5. Cultivate poor sleep habits. Watch television before bed; heck, watch television in bed, or use your smart phone, or tablet, etc. at bedtime. Drink caffeine less than six hours before bed. Wait until night time to argue with your spouse. Have a “nightcap,” which is a short word for “the alcoholic drink that will let you fall asleep more quickly and then wake up at 2 AM and have difficulty going back to sleep.” Eat salty foods before bed to activate your dopamine system and feel a little hyper.
  6. Avoid exposure to natural daylight.
  7. Watch lots and lots of television, or streaming video, or play video games, or surf the internet. The more the better. Strive for the national average of 6 hours or more daily (non-work related).
  8. Spend lots of time on social media. In particular, notice how much your life stinks compared to other people’s (supposed) lives.
  9. Shop for recreation. Spend money you don’t have on things you don’t need and then keep being surprised when, no matter how fancy the clothes or pricy the electronics, you are still, well, you.
  10. Be selfish.
  11. Don’t apologize, and don’t say thank you.
  12. Think a lot about how much other people are unkind, selfish, lazy, and how generally you are not getting your fair share.

Yes, I just described what an awful lot of people do, and yes, if you do enough of these things, you will probably feel depressed. Yet, as can be seen, every single one of these behaviors is optional for most people. Perhaps someone has physical challenges that prevent them from being active, but otherwise, these all represent choices made, choices which could be changed. If you were to do these things, and feel sluggish, unhappy, uninterested in life, helpless to make things better, etc., and reported this to your doctor, you could easily be diagnosed with depression.

The label depression, of course, is itself suspect. Within the mental health field, we are well aware of a dirty little secret. This secret is carefully hidden by pharmaceutical companies from the unsuspecting, suffering, and happiness-seeking public. That is, the criteria for almost every mental disorder diagnosis is a checklist. Committees review the research, argue about what should and should not be on the various checklists, have professional feuds, and publish the criteria. People are then diagnosed based off a checklist of symptoms or complaints. Those categories are fuzzy – a complaint I hear regularly from graduate students who, perhaps naively, expect pure, clear science. As soon as one set of criteria is published, the process starts all over again. This is how it came to be that, in the current diagnostic manual for the American Psychiatric Association, there is no such thing as bereavement. If you are still moping around after two weeks because someone you love has died, the American Psychiatric Association, in its infinite wisdom, has decided you meet criteria for Major Depressive Disorder. That’s the same Major Depressive Disorder diagnosis that many forces are pushing us to believe is simply a brain disease that requires lifelong treatment. I am not being sarcastic or flippant; it’s their decision, not mine. I was Hospice-trained and, even absent that, I am human and understand that bereavement is a long and painful process, even for the resilient among us.

The decision to eliminate the “bereavement exclusion” was supposedly made, in part, to allow people to use health insurance to pay for grief counseling. (At least, that’s the gossip I hear in mental health circles.) In other words, you are despondent. Someone has died. You go to a counselor. They diagnose you with depression, which is supposedly a brain disease, because you meet checklist criteria. You are now labelled with what many people assert is a lifelong condition due to your sick brain. You will now be able to have insurance cover your counseling (after your deductible has been met, of course). The diagnosis of a major mental disorder will last forever – long after you have forgotten whether you paid a copay or full fee for a handful of sessions, or went to a support group in a church conference room that a therapist facilitated as a volunteer.

Depression is worth discussing as one of the most common diagnoses. Psychiatrists and other physicians provide prescriptions for antidepressants, for example, to about 15% of the adult population annually – and many assert that depression is just a disease, like any other disease, and you have to face that you will be sick and need medication for the rest of your life. If that is the case, then why criticize the Pentagon for being concerned about someone whom psychiatrists assert has a lifelong brain disease having their finger on a trigger, or button, or sensitive data? Why should one person with a particular diagnosis be placed on perpetual disability and another maintain top secret clearance? Which do the people complaining about how the military stigmatizes mental health want?

To be clear, this is not unique to the military. People seek counseling, are unwittingly diagnosed, and discover later that they are deemed mentally ill and a high risk for suicide; perhaps their life insurance rates increase, or their health care premiums increase, and when the premium bills come in, they can’t remember having any mental problems except that time they saw a counselor after their grandparent passed away. The labelling can happen without any mental health treatment at all; if your physician lists a mental disorder as a possible diagnosis (fatigue, depressed mood, and poor sleep being symptoms of lots of problems, psychological and physical) while ordering blood tests (for what turns out to be something medical), that possible mental disorder diagnosis is in your health record, now part of your profile, even if you turned out to be anemic, not depressed.

Even if you are diagnosed with depression, the diagnostic categories don’t adequately describe what is happening, and they should. It is reasonable to expect that professionals, viewing the diagnosis on a chart, immediately discern the difference between these types of experiences:

I’m depressed and exhausted because I’m having hideous nightmares ever since my buddy was blown up and died in my arms” versus,

I’m depressed and exhausted because the 5 years I spent doing meth have caught up with me and my brain has been damaged,” or,

“I’m depressed and exhausted (and right now no one, including me, realizes it’s because I am among the one in 10 women who suffer depression as a side effect of chemical birth control).”

Right now, the label doesn’t differentiate. As you dig into the chart, yes, it’s there – but the most superficial record just shows the diagnosis code.

So, let us not pretend that the military is some big, horrid bully for treating serious mental disorder diagnoses as a possible risk factor for clearance. As long as those in power – throughout the medical, insurance, pharmaceutical and government arenas – are manipulating the definition of mental illness, one can hardly blame the military for being overly solicitous about the mental health of our men and women in uniform.

The conundrum of diagnoses and the risk of damage to one’s life explain why some military personnel are suspicious about seeking mental health treatment. We ought not to assume ignorance when they instead go to chaplains (who may be precisely who is needed) for wise and useful guidance. Similarly, they may choose to be self-paying for marriage counseling, stress management or other issues…off the record and off the base, their privacy is as sacred as mental health treatment ever was, before psychiatry yielded to intrusive insurance, and, as the big player in the mental health field, dragged most mental health professionals with it.


Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

The Cancellation

Another day, another call or email: a couple whose first appointment was scheduled for later this week has cancelled. They have “found a doctor who takes our insurance.” That would be fine but for one detail: the appointment was for marriage counseling.

This could create a dilemma for the doctor who “takes our insurance,” if the clients turn out to be shopping for marriage/relationship counseling. This is because unless one member of the couple is diagnosed with a mental disorder, and the treatment rendered in those conjoint appointments comprise empirically supported treatments for that disorder, it is probably not covered by their insurance, whether the doctor “takes it” or not. No doubt this will be part of the discussion during their first appointment, when they inform the doctor that the problem is not helping Partner A cope with depression or anxiety (or some other mental disorder diagnosis), but rather some sort of relationship problem. Now, if Partner A is depressed, and the treatment involves communication skills combined with cognitive-behavioral therapy, or another empirically supported form of therapy that can involve the spouse as a coach/partner in healing, that’s excellent and ethical practice; not so for relationship problems.

At least I found out in advance, sparing the mutual aggravation of patients who imagined somehow that their marriage counseling needs are someone else’s financial responsibility and of a psychotherapist who expects to be paid for services.

This sort of retraction prior to a first appointment happens sometimes in my practice. “I found someone who takes my insurance.” This, despite my spending 10-15 minutes on the phone before setting that appointment and providing this information about my practice. I don’t contract with health insurance companies: it’s clearly stated on my website, and I tell people during that first, free, fifteen-minute consult.

Why bother mentioning it? There are ethical issues at hand.

To be perfectly frank: health insurance is for health problems.

It ought not to be used to get a discounted rate, subsidized by every other person paying premiums to that health insurance company, for marriage counseling, or premarital counseling, or vocational counseling, or any other normal, problem-of-living, life phase process.

My website clearly states my position on health insurance: I don’t contract with insurers because the bulk of what I do is not billable. I do not want my work with couples to be tainted by ethically questionable gymnastics in which we justify treating the relationship because it will indirectly help with a mental disorder. I will not label children with a brain disease because their grownups are getting divorced and upsetting the children, resulting in a custody evaluator referring the children to me. I will not participate in diagnosing people when I am concerned it is not in their best interest – a position supported, as it happens, by the American Counseling Association.

So, no, I don’t “take” insurance. Insurance cards are not debit or credit cards, anyhow: there’s no “taking.” There’s submitting paperwork and hoping one is eventually paid, or being denied payment and then having to bill the client, who may have been discharged months ago.

I don’t diagnose people for the sake of billing. If a client meets criteria for a diagnosis, what we’re doing is aimed at treating the symptoms of that diagnosis and, after being provided information about the process, the client chooses to submit the information to his/her insurance company, I will provide the appropriate form for the client to try to be reimbursed.

I work with human beings who are having problems in their lives (provided they are in Florida, where I am dually licensed for mental health counseling, and marriage and family therapy), and who want life to be better. They want better relationships and a hopeful outlook; they wish to live with purpose and meaning.

Those are not mental disorders. They are signs of health and hope.


Dr. Lori Puterbaugh, LMHC, LMFT, NCC

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.

What can it be, besides ADHD?

Your child is bouncy. He doesn’t seem to pay attention; she forgets to follow through on tasks. The book bag is a disaster area; necessary books never seem to make it home; and you regularly have to turn around and go home to pick up shin guards or ballet shoes.

Well, what can it be, besides ADHD – the psychiatric diagnosis of Attention Deficit/Hyperactivity Disorder, diagnosed off a checklist and sometimes suspected of being over-diagnosed?

The symptoms associated with ADHD can be due to a wide variety of issues; here are a few:

  1. Stress at home or in the environment. If you are having marital or other family difficulties, your child is stressed – whether you know it or not. Research indicates that a, adults are pretty lousy of telling when children are anxious or worried and b, the children of adults with marital problems, when tested in research studies, have high levels of stress chemistry metabolites in their urine.
  2. Maybe it’s not at home; maybe it’s the environment. Live in a noisy and/or high crime neighborhood? Is your child bullied or afraid of being bullied at school? Sources of ongoing stress will interfere with the parts of the brain that are important to focus, attention and memory.
  3. Insufficient sleep. Is your school-age child getting 9 or 10 hours of quality rest per night? Falling sleep by television, computer, or with a cell phone close at hand? These will all interfere with quality and quantity of sleep.
  4. What are overtired kids like? You know what you do when you’re driving late at night and you are too tired to be driving – so you bounce in the seat, sing too loudly and pretend having the windows open will magically keep you alert? Yeah, well…meet the 3rd grade kid who is up too late because of football or soccer practice a few times a week and fidgets around looking dazed in class.
  5. Insufficient exercise. The recommendation for children is two hours of physical activity a day – real activity, not standing-around-hoping-coach-lets-me-play-this time activity.
  6. Boredom. Brains + boredom = either shutting down and not trying at all OR driving grownups and other kids bonkers. Look out for the introverted or shy child who may shut down and go into dreamland; a lot of gifted children are very introverted and self-contained, and unlikely to be overtly disruptive. They simply tune out.
  7. Frustration. A child who is having difficulty – perhaps an undiagnosed or insufficiently supported learning disability – will often give up and stop trying. Remember that children personalize things; if they are struggling and the grownups act like they “should” be able to “get it,” the child assumes the adults know best and that the child must be flawed/”stupid” etc.
  8. Your (or some other involved grownup’s) inconsistency. If you flipflop on rules, fail to follow through, and run an unpredictable life for yourself and your child, it’s not fair to look at the child who seems scattered or (more likely) is gambling on this being one of those times when you are too stressed or preoccupied and let things slide, and blame the child.

You’ll notice that none of these issues can be blamed on the child. These are all grownups-need-to-pay-attention flags, not “naughty kid” flags. So, before you assume your child has a brain disorder, rule out the many factors that we grownups often unwittingly inflict on children and see if, with a few months of more consistent attention to these risk factors, your child’s behavior and morale improve.

Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.


Avoidant Personality Disorder, Social Anxiety, or Just Shy?

Simple shyness? Social Anxiety Disorder? Avoidant Personality Disorder? What’s the difference? Are we just pathologizing normal behavior? Why so many labels?

Well, the labels exist to help professionals differentiate between constructs. That’s what most diagnoses are: categories put together by committee, identifying particular experiences or patterns of behavior, thinking and/or feeling that tend to co-occur. That’s an extreme simplification, but it’s a good jumping-off point for us.

Shyness is normal-people-speak. It’s the way we describe someone, or ourselves, when we are a little reluctant to “blow our own horn” or “put ourselves out there” (whatever THAT means). A little shyness means some mild worry about doing the right thing, not embarrassing ourselves, and wanting to avoid being a nuisance.

Social Anxiety Disorder (SAD) is a psychiatric label that covers a level of shyness that interferes with someone’s daily life. That’s the test: whether the person’s regular life is constricted by worry about saying/doing the wrong thing in social settings and a tendency to avoid social gatherings or work or school related activities. It’s anxiety: there are both physical symptoms of fight-or-flight (elevated heart rate, for example, or more perspiration) and psychological symptoms (worrisome ideas about being in the spotlight and doing something “stupid,” for example). People with SAD usually have close relationships and get through daily life pretty well, with bumps along the way when big events or unusual circumstances – public speaking at a work meeting, for example, or large gathering – looms.

Avoidant Personality Disorder (APD) is sometimes confused with SAD. ADP is markedly different, though, because it encompasses a global low self-esteem and fear of being judged and found wanting in just about every way. So, for example, the person with some social anxiety has close friendships but might feel a bit anxious about going to a wedding reception with a lot of people s/he doesn’t know. The avoidant person has few close relationships out of fear of people finding them just not good enough to be friends. The APD person suffers anguish before annual performance reviews, and even gentle constructive criticism is received as devastating evidence of how deficient they are.

The fear is not “just in their head.” Fear is always a full-body experience. When a situation seems to be a threat (for the person who suffers with APD) to be judged and found wanting, the body responds before the logical, higher brain has even identified what is happening. So the amygdala has sounded the general alarm – the endocrine system flies into action, and as a result logical assessment is curtailed. Telling someone whose heart is pounding, whose blood is full of adrenaline and a massive dose of glycogen and is primed to run away that they are just overreacting is not helpful. Learning how to manage this, how to recover from the old messages of being “less than” and “not good enough,” is a process, not an instant fix. It can be healed.

There’s much more to these labels and to the details of treatment, of course, but perhaps the useful take-away today is: help is available. A lot of people will find that solid self-help approaches based in cognitive-behavioral therapy research (David Burns, MD’s books are excellent examples of these) quite sufficient for mild to moderate social anxiety. When that anxiety is all-pervasive, and there are few relationships out of fear of being found wanting, and loneliness and fear of being judged rule one’s life, the additional support of a counselor might be more helpful than trying to struggle through alone. Ironically, group psychotherapy can be quite effective for these difficulties – but it’s hard to find them.

If you know someone who is struggling, try to help them get help.


Dr. Lori Puterbaugh

© 2016

Posts are for information and entertainment purposes only and should not be construed to be therapeutic advice. If you are in need of mental health assistance, please contact a licensed professional in your area.