borderline personality disorder : Raising Troubled Kids

How to talk to a difficult teenager – what to say and do

Have hope!

Parents can learn how to talk to a difficult teenager and reduce arguments and negativity. There are good responses for when you and your teenager fight or argue or get stuck in the same negative communication patterns, but there are three very important principles to consider.

What you say and do depends on your unique situation, your difficult teenager, and what the problem is. There are no magic words or actions that work for every teen. It’s up to you to experiment–discover which responses fit your child’s behaviors and customize them.
How you say it will determine success or failure. Doing this well means you must have an iron grip on your own feelings and behavior and not be a parent.
Improvement takes time. Pace yourself for a marathon.

1. Identify what goes wrong

Difficult teenagers typically sabotage dialogue when they experience mental and emotional overload.

As an adult, you know about managing emotions, but your teenager doesn’t have a clue and is too young to articulate what he/she really means or needs anyway–and they know it. Talking with you makes them anxious and insecure.

Circle your teen’s most common sabotage techniques (below) and address one at a time. Learn to spot them the moment they come up, and plan ahead how you’ll respond. You should not tell them what you are doing because it will only feel like blame or insult.

Make excuses – It’s not my fault and I shouldn’t get in trouble.
Lie – keep secrets, fake an attitude to avoid the conversation or hide something
Exaggerate – revise history or express extreme insult or trauma over minor things
“Catastrophize” – assume the worst and that it’s going to be forever
Entitlement – I’m unique, I’m superior, what you say doesn’t apply to me, I get things my way
Hostility – insults and verbal abuse
Overconfidence – I’m exceptional, I already know, you don’t know what you’re talking about
Self-pity – I’m broken and no one cares
Minimize – make light of others’ needs and feelings, deny their actions have consequences
Vague – Guess what I’m thinking/feeling. If you’re wrong it means you (don’t love me, don’t care, are stupid).
Silent treatment – I plan to make you crazy by ignoring you –or- I can’t handle this and want to disappear.
Keep score – I win and it means I get my way (and you’re stupid).
Righteousness – I’m an adult and have rights and can make my own decisions.
Pet me – Praise me, flatter me, agree with me or I’ll make you regret it
Harp – repeatedly bring up a sensitive issue to get you upset, whine about things long resolved

Don’t waste precious energy fretting about your difficult teenager’s immaturity.

2. Prepare yourself emotionally and learn techniques used by therapists

Be a quiet witness, not a participant

To talk to a difficult teenager, mentally take off your parent hat and become a neutral observer without emotions or bias from bad memories. This is absolutely critical because you must be able to remove any negative tone in your voice. Your child reacts to tone of voice more than what is said. Your feelings are certainly important; just don’t allow yourself to express them.

‘Channel’ your inner therapist like an actor who gets into character. Faking it works, and may even help you be more effective. [check out YouTube videos].
Practice quieting your thoughts, and beliefs, and feelings.
Remind yourself you are a good, competent parent; trust yourself and your good intent.
See strengths, pay attention to what’s great about your child
Avoid justifying or explaining yourself. Your teenager can pick up on something you say and use it against you.

In these examples, the parent doesn’t react to the emotions they feel or try to justify themselves.

Reframe – Present a different point of view of the facts, or reveal details that show the ‘facts’ aren’t what they seem.

Teen: “If I don’t do well in this class, you’re going to punish me by sending me to stupid summer school because that’s all you care about are grades.”

Parent: “Last year you had the same concerns at the end of the term, and then I saw you focus and pass the class with a really high grade and be really proud of yourself. I think you will do this again.”

Paraphrase – Say the same thing you heard using different words. This helps your child know if they said what they really meant, and gives them the option to clarify and provide details.

Teen: “You stupid effing b1tch you never care what I think and keep trying to control me and I hate you!”

Parent: “I hear you telling me you want to make more of your own decisions.”

Use “I” Statements – Avoid saying “you” because your child can interpret it as blame or insult regardless of your intent. Simply owning your feelings or stating your observations doesn’t impose your view and is hard to argue with.

Teen: “You said you would help me but all you want to do is see me fail. You could care less about me and even my friends think you’re a bad parent.”

Parent: “I definitely care; I explained the best I could why I can’t afford the time/money right now. I am frustrated by this situation too.”

Validate feelings and explore why

Teen: “You didn’t listen to me when I told you my teacher was picking on me.”

Parent: “Maybe I misunderstood or didn’t think he was treating you differently than your classmates. I’m listening now; can you give me more details?”

Check the facts

Teen: “My friends hate me and I don’t want to be around them ever.”

Parent: “What happened?”

Teen: “They all went to a movie and I wasn’t invited, and told everyone else what a great time they had.”

Parent: “Wasn’t that the day you lost your phone charger? Could they have tried to contact you but your phone was dead and you never got the message?”

Reflect on the bigger picture

Teen: “School sucks. It’s never helped me and everyone there is an a55hole and I already know what I need to know anyway. Don’t try to make me stay.”

You: “OK, school isn’t working for you. Do you have plans if you drop out? a job or a class for a new skill or occupation? You are growing up and will be on your own someday, and you will want your own money.”

Deescalate a heated moment without placing blame or accepting blame. You might apologize or change the subject temporarily.

Teen: “Stop f**king treating me like you’re my therapist!”

Parent: “I’m sorry that it feels that way. I’m not your therapist but a parent trying to communicate with their son/daughter the best they can. I need to check my messages so we’ll talk about this later. Can you go make yourself some tea?”

Other ways to deescalate:

Take a time out so you and your difficult teenager can calm down and gather your thoughts.

Converse via text, even in the same house, even in the same room. No talking, only texting. This works surprisingly well.

Talk to your teenager through a door, you do not need to look at each other, and perhaps your teen feels safer in another room.

3. Accept the limits

The goal is not to stop your difficult teenager’s challenging behaviors but teach them how to manage. How you talk to your difficult teenager only needs to be healthy, which is not necessarily positive or comfortable.

A healthy conversation means both parties:

Feel heard and understood even if there’s disagreement

Feel safe because they expect no emotional assaults

Feel enough trust and to talk again later

4. Pay attention to what improves or wrecks a conversation.

Visualize yourself as a wild animal trainer trying to teach an uncooperative creature to perform a task. You try various techniques and expect the animal to resist. You keep trying until the resistance diminishes, and then you start supporting with positive feedback. Some of the techniques below will work; some will fail spectacularly. When you find those that work, mix them up or your difficult teenager will catch on and try other tactics.

Let your difficult teenager rant for a while. Teens often vomit out emotions regardless of how they sound or if they make sense and parents don’t need to respond.

Ask why and how. Explore the underlying cause by using simple questions that can’t be answered with Yes or No to help them identify and articulate what they mean and need.

Redirect. Change the subject, or have a pre-planned list of actions for ending a tough dialogue.

DEFLECT for manipulation and button-pushing:

“Consciously ignore” (pay attention but mentally or physically withdraw) – Pretend you didn’t notice when he/she resorted to blaming, demanding etc.

Change the subject – ask what they want from the grocery store; ask if they remember an upcoming event

Escape – excuse yourself for the bathroom. Say you forgot to call someone back who left an important voicemail.

SUPPORT for anxiety, whining, and obsessive thoughts:

“We’ll get through this together;” “I am looking after you.”

Confidently reassure, and point out what’s going well.

Deny false charges against you without explaining, just state the fact. “I did not say that;” “I am not accusing you…” Period.

Apologize immediately when guilty. “You’re right. That was not the right thing to say and I apologize,” nothing more. You may be guilt-tripped into apologizing multiple times, so say something like: “I apologized and it was the right thing to do. I haven’t done it again and won’t apologize again.”

Set simple boundaries like you might for a fussy young child. “You can get angry and run to your room, but you can’t slam the door.” Remember that anger is normal, but harm is not acceptable. Screaming is normal, but ugly insulting words are not acceptable. Depression and sadness is normal, but isolating is risky–they need to be in the presence of others.

No offering reasons or lessons. Conflict is not a teachable moment. Your teen absolutely cannot reason when they’re flooded with emotion. Trying to teach something can seem patronizing and disinterested in their concerns.

Appeal to a higher self: During a fight or argument, listen carefully for something your child says (without prompting) that reflects good values and character, even the tiniest teensiest thing. Incorporate their stated good values in all your communications.

5. Help your difficult teenager think about their future

You may have tried to motivate your teenager to think about their future, but ultimately your teenager takes responsibility for the details. This helps: Provide a list of open-ended questions, worksheet-style, which they answer for themselves. Examples:

What do I care most about?
How can I feel better when I’m upset?
How can I cope with boredom?
What am I good at?
What are three things I’m most thankful for, why?
Who do I trust and why do I trust them?
Where do I see myself in 5 years? How will I get there?

Ideally they share their answers with you but this should be optional. If you do see them, absolutely avoid guiding or correcting answers even if you think they’re wrong! The point is to start them pondering and exploring. If they write “kill myself” or “run away” or “use drugs”, don’t push back—they KNOW what you think—you might ask if there are other options.

Teens are innocent and pure in a way adults are not. They have standards and values (unless they are a sociopath). Look for opportunities to appeal to these values.

Remember this…

…when they do this.

Good luck.

You can find additional practical and common sense approaches to parenting here: Solid Wisdom For Parents Of Troubled Children And Teens

Borderline children – how they function and how you can help

Borderline personality disorder makes a child wonderful yet horrible; lovely yet vindictive; a great friend or manipulative bully; anguished or glowing with joy; self-hating yet self-important; self-centered but also charitable.

Are you ready to bang your head on a wall? Or praying for the day your child turns 18, when you can change the locks on your doors? Children with borderline personality disorder (BPD) can traumatize everyone around them.

Children with BPD believe others will abandon them, and this makes them do one of two things:

1. Do everything possible to obtain and keep love and admiration;
2. Or if they detect the slightest hint of disapproval, blame themselves or others so as to feel they made a decision to break or run away from a relationship. This can disguise horrible feelings of abandonment.

A borderline child can be very engaging and affectionate… sometimes at random and sometimes when they want something. Because they can be vindictive, they may also turn on charm as a way to embarrass you in front of others (such as in a meeting with a teacher or family counselor). Since they often seem wonderful to other people, parents have been judged. People often suggest they take care of their own issues instead.

Even if their manipulation or drama can be relentless, strive for compassion. Trust me, your borderline child will suffer more than you in every important aspect of life. They can make a mess of their relationships because of hurtful or clingy behavior. Or they create a toxic work environment. Or they drive away good friends, hate them for leaving, and suffer from loneliness.

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

A study published in 2008 in Science showed that brain activity in people with borderline personality disorder was abnormal—their brains lack activity in the ‘cooperation’ and ‘trust’ regions, called the bilateral anterior insula. People with borderline personality disorder do not have an internal, natural sense of fairness or social norms, and distrust is their default mentality. Some suggest that borderlines do not receive the attention they need as an infant and toddler. Early neglect is also a predictor of reactive attachment disorder, which has similar trust issues.

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

The brain of a borderline person showed no activity whatsoever during the teamwork game.

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

From infancy, those who were later diagnosed with borderline personality were more sensitive, had excessive separation anxiety, and were moodier. They had social delays in preschool and many more interpersonal issues in grade school, such as fewer friends and more conflicts with peers and authorities.

As teenagers, borderline children can be promiscuous; impulsive and assaultive; more likely to use drugs and alcohol; and more likely to cut themselves and attempt suicide. “…research shows that, by their 20’s, people with the disorder are almost five times more likely to be hospitalized for suicidal behavior compared to people with major depression.”

Evidence for hope

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

Advances have been made in recent years. One study tracked borderline patients who had been hospitalized at least once over a 10 year period. With follow up treatment “93% of patients achieved a remission of symptoms lasting at least two years, and 86% for at least four years.” Published in The American Journal of Psychiatry, the research argues that once recovery has been attained, it appears to last. (from “Trying to Weather the Storm”, by S. Roan, September 07, 2009, Los Angeles Times)

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

Treatment

Psychotherapy is the primary treatment of BPD, and the gold standard is dialectical behavior therapy (DBT), which helps the person attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning. It simply teaches coping skills so patients learn to control their emotions, calm down, and not destroy relationships. Medications support the therapy by reducing depression or anxiety and self-destructive behavior.

(from “What Therapy Is Recommended for Borderline Personality Disorder in Adolescents (13-17 years)?” by M. Muscari, 2005, http://www.medscape.com/viewarticle/508832)

When to hospitalize:

In an emergency, when your child has serious suicidal thoughts or an attempt, and/or is an imminent danger to others, or is incapable of calming down and functioning.

Consider psychiatric residential care when your child has persistent suicidal thoughts, is unable to participate in therapy, has a co-morbid (co-existing) mental disorder (e.g. bipolar, depression, narcissistic personality disorder), a risk of violent behavior, and other severe symptoms that interfere with living.

Other mental health supports your borderline child may need:

Treatment for substance abuse.
Therapy that focuses on violent and antisocial behaviors, which can include emotional abuse or physical abuse, baiting, bullying, and sexualized behaviors. (The most effective therapy is DBT or Dialectical Behavioral Therapy.)
Therapy that also focus on trauma and post traumatic issues if present.
Reducing stressors in the child’s environment. Most children with BPD are very sensitive to difficult circumstances, for example: an emotionally stressful atmosphere; internal and external pressures to succeed or change; inconsistent rules; being around others who are doing better than them.

What parents and caregivers can do

With a co-parent or support person: Maintain a united front.
Communicate privately with each other to effectively set limits. A BPD child will do everything in their power to split authority figures against each other!
Have each other’s back even if you’re not in full agreement.
Never ever give away power by making democratic decisions or explaining your reasoning. Anything you say or do will be challenged or used against you in the future.

Maintain family balance.

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

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

Become skilled in Dialectical Behavioral Therapy (DBT). It is the gold standard for treating
Borderline Personality Disorder. It is the only therapy proven to promote genuine behavioral change and improve mental health. You can ask questions or bring your child back to reality with the following examples.

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

For specific examples of what your borderline child will say and for how you can respond, see: How to talk with your difficult teenager – what to say and do.

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

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

A couple I know fully informed their borderline son that all internet activity would be tracked, as well as cell phone calls. The father also installed cameras in the home, at the front and back doors, in plain sight. Nevertheless, their son continued with bullying and verbally abusing his siblings right in front of those cameras, and he would get caught and deny it each time. His denials in the face of clear evidence became a great source of private amusement for his parents.

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

Never expose your heart like this! Armor yourself emotionally. Visualize those knives as fluff balls, or visualize your child as a toddler with a just another temper tantrum. Find something that works for you and help the co-parents and siblings armor themselves too.

Address your own PTSD! Families who live with a borderline child often need help coping with bullying, wrenched emotions, and the instability that person brings into the household. A parent or family member may need their own therapy, antidepressants, and self-care skills for reducing anxiety.

Simple self-care for you and other family members

Three or more (very) deep breaths when stressed, the brain needs oxygen to begin a calming process. Singing is a superb option.
Magnesium or Kava kava, these substances naturally help calm nerves
Sleep in a dark, cold room is the best way to promote deep sleep. Avoid screen time an hour before bedtime.
An activity that feeds your soul, such as a hobby, a loving pet, a gripping novel, just playing
Direct support from a trusted friend–face-to-face is ideal, but calls, texts, and emails as needed are really helpful too.

Characteristics of untreated borderline personality disorder in adulthood

Good things: They can be very financially and publicly successful in many fields and hold positions of authority, and often succeed in the creative arts and especially acting. They are so perceptive that they can ‘channel’ any person they want. They can be enchanting, and alluring, easily attracting devoted fans, friends, and lovers.

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

Help your borderline child with each of these aspects!

Chronic fear of abandonment which results in a constant search for companionship, no matter how unsatisfying.
Clinging and distancing: Disruptive relationships due to the person’s alternating clinging and distancing behaviors. When clinging, they may exhibit dependent, helpless, childlike behaviors. They can over idealize the person they want to spend their time with, constantly seeking that person out for reassurance. When they cannot be with their chosen person, they exhibit acting-out behaviors, such as temper tantrums and self-mutilation. They distance themselves by being hostile and insulting, usually arising from discomfort with closeness.
Splitting: Splitting arises from the person’s inability feel people are safe, and is the primary defense mechanism in BPD. They view all people, including themselves, as either all good or all bad.
Manipulation: Separation fears are so intense that people become masters of manipulation. They will do just about anything to achieve relief from their separation anxiety, but their most common ploy is to play one individual against another.
Self-destructive behaviors: Threats are most often manipulative, but some acts can prove fatal. Cutting is very common. Suicide attempts are common yet often happen in relatively safe scenarios, such as swallowing pills at home while reporting the deed to another person. Another behavior is to set up a scenario where they are victim so as to get attention and love.
Impulsivity: Extremely rapid shifts in mood can lead to substance abuse, binge eating, reckless driving, sexual promiscuity, and excessive spending or gambling. These are similar symptoms of bipolar mania, but BPD behaviors happen for different reasons, usually in response to real or imagined abandonment.

You really can turn your borderline child’s future around.

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What will happen in your troubled child’s future?

Are you scared for your child’s future? Is he or she is falling behind? On a scale of 1 to 5, where 1 is “Normal” and 5 is “Worst Case Scenario”, what will your child’s future adulthood look like?

This chart depicts a spectrum of outcomes of mentally ill children when they become adults. No matter how ill your child is, if he or she gets support and treatment early, their future adult life could end up in the NORMAL column, and out of the RED column. A network of family, friends, and professional staff can keep them from the worst-case scenario in the far right column, and move them in the direction of normalcy.

“Wellbeing” is possibly the most important.

This is a checklist of childhood problems that lead to poor future outcomes as adults. Jump on them one by one.

Friend problems: they have inappropriate friends, or no friends, or they mistreat friends (and siblings).
Behavior problems: they do or say disturbing things (swearing, hurting, breaking, manipulating, sinking in depression, attempting suicide…). Everyone is stressed.
School problems: disruptive behavior; poor grades (or a sudden drop in good grades); bullying or being bullied.
Health problems: physical health problems become mental health problems, and vice versa:
- trouble with sleep
- digestive system and gut problems
- poor diet and lack of exercise
- epilepsy or neurological disorders
- hormones during puberty
- substance abuse.

Age 16, starting mental health treatment

We designate legal adulthood between the ages 18 and 21. That’s too young. Many normal healthy young people at this age are immature and irresponsible, but your son or daughter may lag well behind them. Your child may need support and rescuing well into the 20’s or early 30’s–this is not unusual.

You’ll survive the marathon of tough years by pacing yourself, finding support for yourself, and protecting your mental health.

There is reason for hope. Your child may take many horrible directions in their teens and 20’s, and you may feel hopeless about their future, or helpless as you witness their life nosedive. If you can hang on and marshal support, your child will find a circuitous path to recovery. It will have sharp turns and back steps and falls, but they’ll find it… and enter stable adulthood.

Age 20, after consistent mental health treatment

Some parents and families have seen the worst. They’ve endured violence due to their child’s addiction; sat in court when their son or daughter was convicted of a crime; or they waited in the Emergency Room when their son or daughter was admitted for psychiatric care. They also lived to see their child achieve the sanity to finish their education, support themselves, develop good relationships, and get that future you always wanted for them.

How two parents handled a “worst case scenario” and supported their child’s wellbeing:

These are true stories of mothers who stuck by their very ill adult children and provided what little they could to bring a bit of wellbeing. These mothers found some peace by simply doing what they could. Their child still had hope.

One had a grown son with schizophrenia and a heroin addiction who lived in squalor in supported housing. He spent all of his disability assistance money on heroin and nothing else. Her efforts to help him met with verbal abuse and threats of violence, and she feared for her safety. What could she do, witness his slow suicide by starvation or overdose? She arranged to visit him once a week in the parking lot, and brought 2 sacks of groceries in the trunk of her car. He was to come out and get the groceries while she stood at a safe distance. This worked. He was still verbally abusive when he got the groceries, but he got food and she stayed safe. Did he have wellbeing? Was his life humane?

He lived indoors
He had enough food and clothing
He had encounters with social services and police, which led to some health care
A support system was available if he was ready for help.

One had a son addicted to methamphetamine who was lost to the streets. One day, she discovered a nest of old clothes and rags in an overgrown area behind her garage, and instinctively knew it was from her son. “Good,” she thought, “He’s alive; I can keep him safe.” She rarely saw him come and go, but she replaced the rags with clean blankets and a sleeping bag, and put out food for him, and provided a tent. She couldn’t free her son from addiction, but she could keep him safe from the streets and its desperate people, and fed and sheltered in a way he accepted.

Like in the previous story, her son had a modicum of safety and support, and ongoing monitoring if he was ready for help.

–Margaret

Please share your story.

What to know about psychiatric residential treatment

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

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

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

What to ask about the staff:

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

What to ask about programs:

Does the program specifically identify parent/family involvement as part of treatment? Does it emphasize parent partnership with staff? Ask. Whether you live close or far from the center, even out-of-state, you should be regularly included in conversations with staff about your child’s treatment. You should also be included in a therapy session with your child periodically; some facilities can connect with you over Skype. Your child’s success in psychiatric care depends on their family’s direct involvement.
The program should coach you in specific parenting approaches that work for child’s behavioral needs. While your child is learning new things and working on their own changes, you must know what to establish back home when they return.
You should be informed why your child is getting the treatment or behavioral modifications he/she is receiving.
Last and most important: when your child leaves, there should be a discharge meeting and a discharge plan. What this means: all staff who worked with your child get together with you and discuss what treatment should continue once they go home. Medication management and therapy is identified in advance, appropriate school accommodations are discussed, changes in the home environment are discussed if needed… You should never leave without knowing what comes next in the months following care.

Body health is brain health, and vice versa.

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

Is your child emotionally safe as well as physically safe?

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

What to ask about the business itself:

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

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

Good luck.

What was your experience when your child was in residential care? Please share your comment so others can learn.

Is my teen ‘normal’ crazy or seriously troubled?

A high percentage of teenagers go through a rebellious or ‘crazy’ phase that is normal for their age and brain development. The difference between normal teen-crazy and truly troubled behavior is when the teenager falls behind his or her peers in critical areas. At a bare minimum, a normal teen will be able to do the following:

Attend school and do most school work if they want to;
Have and keep a friend or friends their own age who also attend school;
Develop a maturity level roughly the same as his or her peers;
Exercise self-control when he or she wants to;
Demonstrate basic survival instincts and avoid doing serious harm to themselves, others, or property.
Enjoy activities that interest them.

It is normal for many teens to be inconsistent, irrational, insensitive to others, self-centered, and childish. Screaming or swearing is normal–regard this the same as a toddler temper tantrum. Outlandish imagination and ideas are normal in the adolescent phase too. These are behaviors that crazy teens grow out of unless something else is holding them back. What you’d call troubled behavior, the kind that necessitates mental health treatment, is a matter of degree.

This is your challenge: How do you tell the difference? Troubled teens with mental disorders have the same challenging behaviors as ‘normal’ crazy teens… How do you know if they need serious mental health treatment? Look for pervasive patterns of social and behavioral problems that stand out against their peers, patterns which persist or occur in different settings. Look back at how long these patterns have been occuring. Are the patterns repeating themselves, or are behaviors increasingly worse? Do you You your troubled teen is slipping behind and won’t grow out of it.

Signs of abnormal behavior

A sudden change in behavior.

An abrupt change in friends and interests, and loss of interest in things your teenager used to enjoy. This might indicate the onset of a serious mental illness or drug use or both.
Unusual ideas, or obsessive beliefs, or unrealistic plans, see: “Unsettling: what psychosis looks like in children and young people.”
Others think there is something abnormal about your child. (e.g., your child’s friend comes forward, their teacher calls, other parents keep their children from your child, or someone checks to see if you’re aware of the nature of his or her behaviors).

Unsafe behaviors (“Unsafe” means there’s a danger of harm to themselves or others, property loss or damage, running away, seeking experiences with significant risk (or easily lured into them), abusing substances, and physical or emotional abuse of others.)

If a troubled teenager does something unsafe to themselves or others, it is not an accident, but something impulsive, intentional, and planned.
They have a history of intentional unsafe activities.
They have or seek the means to do unsafe activities.
They talk about or threaten unsafe behavior.

How psychologists measure the severity of a child’s behavior

“Normal” is defined with textual descriptions of behaviors, and these are placed on a spectrum from normal to abnormal (or “severe emotional disturbance” – SED). Below are a few examples of a range of behaviors in different settings. These descriptions are generalizations and should not be used to predict your child’s treatment needs, but they do offer insight into severity and the need for mental health treatment.

School behaviors

Not serious – This child has occasional problems with a teacher or classmate that are eventually worked out, and usually don’t happen again.

Mildly serious – This child often disobeys school rules but doesn’t harm anyone or property. Compared to their classmates, they are troublesome or concerning, but not unusually badly behaved. They are intelligent, but don’t work hard enough or focus enough to have better grades. They could use help from a school counselor, teachers, and possibly a therapist for themselves or the family.

Serious – This child disobeys rules repeatedly, or skips school, or is known to disobey rules outside of school. They stand out in the crowd as having chronic behavior problems compared to other students and their grades are poor even if they’re very intelligent. This child needs mental health or substance abuse treatment.

Very serious – This child cannot be in school or they are dangerous in school. They cannot follow rules or function, even in a special classroom, or they may threaten or hurt others or damage property. It is feared they will have a difficult future, perhaps ending up in jail or having lifetime problems. If they cooperate, this child requires intensive mental health and or substance abuse treatment.

Home behaviors

Not serious – This child is well-behaved most of the time but has occasional problems, which are usually worked out.

Mildly serious – This child has to be watched and reminded often, and needs pushing to follow rules or do chores or homework. They don’t seem to learn their lessons and are endlessly frustrating. They can be defiant or manipulative, but their actions aren’t serious enough to merit intensive treatment, though a school counselor or private counselor would be very beneficial.

Serious – This child cannot follow rules, even reasonable ones. They can’t explain or take no responsibility for their behavior, which can include damage to the home or property, or harm to themselves or others. They need mental health treatment or substance abuse treatment.

Very serious – The stress caused by this child means the family cannot manage normally at home even if they work together. Running away, damaging property, threats of suicide or violence to others, and other behaviors require daily sacrifices from all. Police are commonly called. This child needs intense psychiatric treatment and/or substance abuse treatment, and likely residential treatment.

Relationship behaviors

Not serious – The child has and keeps friends their own age, and has healthy friendships with people of different ages, such as with a grandparent or younger neighbor.

Mildly serious – This child may seem extra immature. They will argue, tease, bully or harass others, and most schoolmates avoid them. They are quick to have temper tantrums and childish responses to stress that always require extra attention from parents and caregivers.

Serious – The child has no friends their age, or risky friends, and can be manipulative or threatening. They can have violent tendencies, poor judgment, and take dangerous risks with themselves and others. They don’t care about others’ feelings, or may readily harm others physically or emotionally. This child needs therapy and psychiatric mental health treatment or substance abuse treatment.

Very serious – The child’s behavior is so aggressive verbally or physically that they are almost always overwhelming to be around. The behaviors are repeated and deliberate, and can lead to verbal or physical violence against others or themselves. This child needs intensive psychiatric and/or substance abuse treatment.

Pay attention to your gut feelings.

If you’ve been searching for answers and selected this article to read, your suspicions are probably true. Trust your intuition. Most parents have good insight into their child. If you’re looking for ways to “fix” or change your child, there just aren’t any easy methods or medications or therapies to do this except over time. Treatment means multiple life changes in addition to medication and therapy, and these can include help for insomnia, a change in diet, treatment for digestive system problems, and household changes to reduce stress.

Mental illness is serious and recovery is a long slow process. It is understandable if you want them to recover quickly–your stress can be intolerable. Avoid pushing for recovery because it will only stress your child and lead you to disappointment. Instead, cooperate with professionals (teachers, treatment providers), and prepare yourself for a parenting marathon. What’s the best way to prepare? Work hard on your own mental health and wellbeing. Lower your expectations for steady progress. This advice and wisdom from other parents may help you face this daunting task.

Early treatment, while your troubled teenager is young, can prevent a lifetime of problems. Find a professional who will take time to get to know your child and you and the situation, and who will listen to what you have to say–a teacher, doctor, therapist, psychiatrist or other mental health practitioner.

–Margaret

Your comments are encouraged. Your story helps others who read this article.

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Faith can help, and harm, a family’s mental health

When faith helps

Most of the time, people can heal and find peace and self-acceptance through faith. All the world’s great faiths, those that have lasted centuries, are kept alive for this reason. All have common themes of healing and service to others. When things go poorly, meditation and prayer, with others or in private, lead to connection and wholeness. Faith reveals that things are better, and will be better, than they seem.

When families are in crisis because of their troubled child, parents tell me they depend on faith, even parents who don’t profess a faith practice. They say it’s their only source of strength. Most families with a child who is sick, disabled, or mentally ill will go through dark times, when a parent’s world is simply too overwhelming. Most often, no answers are forthcoming, nor any rescue. The only choice is to hand over their burden to a “higher power,” God, the Buddha, Allah, the Great Spirit… This act of “handing over” is a foundation of healing in Alcoholics Anonymous, Narcotics Anonymous, and dialectical behavioral therapy (DBT).

Few things help a family more than a supportive community of believers. There will be one person who listens to a frightened parent on the phone, and another person who takes a traumatized sibling on an outing, and another person who provides hugs and cookies. If a mentally ill child continues to decline, a good faith-based support network will stay on. The child may not thrive, but the family does, and has the strength and forbearance to handle the years’ long task of supporting their mentally ill loved one.

Science shows that faith results in better lifetime outcomes for a child

This writer typically trusts science, but in the depths of my family’s despair, only faith and the prayers of others kept me from falling apart.

There are scientists among the faithful who have asked the question: does faith really help the mentally ill? In another blog post, Spirituality and mental health, some research are summaries of research going back 36 years. (Follow this link for the research citations.) The answer? Yes, faith makes a real and measurable difference in improving mental health.

More recent scientific research shows clear evidence from brain scans that meditation and prayer change brain electrical activity, from anxious or agitated to serene and grounded. The person actually feels and behaves better. This article has more information on this, Yoga – Safe and effective for depression and anxiety.

Like prayer, “talk therapy” or psychotherapy also shows improvement on brain scans. Imagine, just talking with someone improves the physical brain. According to the article appended below, “When God Is Part of Therapy,” many prefer therapists who respect and encourage their faith. It just makes sense.

When faith harms

This section is a personal appeal to faith communities who have unconscionably failed families and their children with mental disorders.

Faith communities depend on people, and people have biases and foibles. Many of ‘the faithful’ hold negative beliefs about others, right or wrong. Children who suffer, and their families, are identified as possessed, of evil character, disbelievers, victims of abuse, or cruelest: those who are paying for their sins. Families are repeatedly told these very things today.

“Sometimes, people hide from the Bible. That is, they use the Christian holy book as an authority and excuse for biases that have nothing to do with God.”
–Leonard Pitts Jr., Miami Herald

Stigmatization from a faith community is a cruel betrayal.

A child’s inappropriate behavior is not a choice, it is a verifiable medical illness, one with a higher mortality rate than cancer: Mental illness more deadly than cancer for teens, young adults. Families with sick children need support; our sense of loss is devastating.

Testimonials

Mother with five children, one with bipolar disorder:

“We were members of our church since we were first married, all our daughters grew up here, but when my youngest spiraled down, I was told the sins of the father are visited on the sons. Or we weren’t praying enough. I knew they thought (Dad) had done something bad to her. We left and went church shopping until we found a pastor who understood and supported us.”

Mother of two children, one with acute pervasive development disorder:

“I wish we had a “special needs” church. We’re so afraid our kid is going to say something and we’re not going to be accepted. We haven’t gone to church for years because of this. They just turned their backs on us, it happened to another family with a deaf child. They avoid parents in pain. Deep down in my heart I believe in the Lord, but there are days when I wonder “where is God?” People call out to pray for a job, or a kid’s grades, but we wouldn’t dare ask for us, no one would get it, we’d be told we were bad parents or didn’t punish him enough.”

Mother of two children, one with schizoaffective disorder:

“When I went up to the front to light a candle and ask for a prayer for my daughter, I expected people would come up afterward and give a hug or something, just like with other families with cancer and such. But it didn’t happen. No one even looked at me. I left alone and decided never to go back.”

Some good news

FaithNet

The National Alliance on Mental Illness (NAMI) has recognized the need for the mentally ill to be part of faith communities, and the negative experiences most face when they attempt to participate in a religious community. NAMI started FaithNet to encourage and equip NAMI members to engage with and share their story and NAMI resources with local faith groups, and appeal for their acceptance.

Key Ministry

Key Ministry: Welcoming Youth and Their Families at Church
Stephen Grcevich, M.D., president, Key Ministry and child & adolescent psychiatry in private practice, Chagrin Falls, Ohio

“Key Ministry believes it is not okay for youth living with mental illness and their families to face barriers to participation in worship services, educational programming and service opportunities available through local churches.”

Churches in American culture lack understanding of the causes and the needs of families impacted by mental illness, which poses a significant barrier to full inclusion.

“A study published recently by investigators at Baylor University examined the relationship between mental illness and family stressors, strengths and faith practices among nearly 5,900 adults in 24 churches representing four Protestant denominations. The presence of mental illness in a family member has a significant negative impact on both church attendance and the frequency of engagement in spiritual practices.” When asked what help the church could offer these families, they ranked “support for mental illness” 2nd out of 47 possibilities. Among unaffected families, support for mental illness ranked 42nd.

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When God Is Part of Therapy
Tara Parker Pope, March 2011, New York Times

Faith-based therapy is growing in popularity, reports Psychology Today, as more patients look for counselors who can discuss their problems and goals from a religious frame of reference.

Studies show that people prefer counselors who share their religious beliefs and support, rather than challenge, their faith. Religious people often complain that secular therapists see their faith as a problem or a symptom, rather than as a conviction to be respected and incorporated into the therapeutic dialogue, a concern that is especially pronounced among the elderly and twenty-somethings. According to a nationwide survey by the American Association of Pastoral Counselors (AAPC), 83 percent of Americans believe their spiritual faith and religious beliefs are closely tied to their state of mental and emotional health. Three-fourths say it’s important for them to see a professional counselor who integrates their values and beliefs into the counseling process.

The problem for many patients in therapy is that many patients are far more religious than their therapists.

Nearly three-fourths of Americans say their whole approach to life is based on religion. But only 32 percent of psychiatrists, 33 percent of clinical psychologists and 46 percent of clinical social workers feel the same. The majority of traditional counselor training programs have no courses dealing with spiritual matters.

When children are hospitalized with other ailments, the family draws sympathy and support from others. But because of mental health stigma, most families like ours don’t when our child is hospitalized. If not blame, we are second-guessed, or as bad, met with silence or a change of subject.