NYC Psychotherapist Blog

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Thursday, March 25, 2010

Adolescent Depression Among 18 Year Olds: Child or Adult?

Adolescent Depression Among 18 Year Olds: Child or Adult?

Adolescent Depression Among 18 Year Olds:  Child or Adult?
Over the years, I've seen a number of parents who come to psychotherapy to deal with their own fear, frustration, and anxiety related to an 18 year old daughter or son who refuses to get help for depression. With regard to mental health decisions, in New York State, we consider an 18 year old to be an adult who can make his or her own decisions about getting mental health treatment. A concerned parent, who is worried about the welfare of his or her child, cannot force an 18 year old to get help if the teen doesn't want it. This raises a lot of complicated issues:

  • Even though the law considers an 18 year old to be an adult with regard to participating in mental health treatment, does an 18 year old always have the psychological maturity and judgment needed to make this decision?
  • Given all the hormonal and psychological changes that go on during adolescence, does an 18 year old always know what's in his or her best interests regarding psychological health?
  • How does teenage rebellion against parents and authority figures factor into this issue?
  • How does the depression itself affect an 18 year old's ability to make sound decisions for him or herself in this situation?
What is Adolescent Depression?

What is Adolescent Depression?
Adolescent depression is a psychological disorder that occurs during teenage years with symptoms of persistent sadness, loss of interest in his or her usual activities, loss of self worth, and discouragement. In many cases, teens will start to isolate themselves from family and friends. In some cases, teens might turn to alcohol or drugs to self medicate their depression. In more severe cases, teens might make impulsive attempts or gestures to commit suicide. There might be other symptoms from other psychological disorders such as anxiety, anorexia, bulimia, compulsive overeating, self mutilating, hair pulling, and other similar symptoms. See below (What Are the Symptoms of Adolescent Depression?)

What Causes of Adolescent Depression?

What Causes Adolescent Depression?
Depression during adolescence is not unusual. Some of the causes of depression in teens might be:
  • hormonal changes that occur during adolescence
  • stress associated with the normal process of maturing and developmental change
  • a reaction to a disturbing event: the death of a friend or loved one, the breakup of a relationship, problems at school, and other similar issues

Teens who are Most Vulnerable to Depression:

Teens Who Are Most Vulnerable to Depression
  • have low self esteem
  • are highly critical of themselves
  • have little sense of control over stressful events that occur to them
  • have been sexually, physically or emotionally abused or emotionally neglected
  • often come from a family with a history of depression
  • often have poor social skills
  • often feel that they don't "fit in" with their peer group
  • have an unstable home life
  • often have parents who are divorced
  • experience the loss of a parent

What are the Symptoms of Adolescent Depression?

What Are the Symptoms of Adolescent Depression?
  • acting out behavior (misbehaving in school, acting defiant with parents)
  • changes in appetite (either increase or decrease)
  • criminal behavior (shoplifting, alcohol or drug abuse, selling drugs, etc)
  • persistent sadness
  • irritable mood
  • difficulty concentrating
  • difficulty making decisions
  • problems with memory
  • sleep problems (either problems with insomnia, excessive sleeping or day time sleepiness)
  • excessively irresponsible behavior
  • excessive guilt
  • problems in school, including failing grades, fighting with teachers or other students, cutting classes, etc.
  • thoughts about suicide, making plans to commit suicide or actual suicide attempts
  • substance abuse or other forms of addictive behavior (gambling, acting out sexually)
  • excessive worry or preoccupation about death
  • significant weight change (either gaining or losing)
Is it Depression or Something Else?
Depression is difficult to diagnose in teens due to hormonal and other developmental changes that go on during this phase of life. Some of the above symptoms are just a normal part of being a teen and do not necessarily mean that your teen is depressed. A psychotherapist or psychiatrist, who specializes in working with teens, should be consulted to make a differential diagnosis. Also, it's a good idea to consult with your medical doctor to rule out any medical causes. A doctor who is knowledgeable about substance abuse can also rule out alcohol or drug abuse.

Depression Before and After Age 18:
Prior to the age of 18, as a parent, you can make the decision as to whether or not your child gets help. It's always better to include teens in on the decision making process, if you can, rather than trying to force them to get help. Also, when teens become involved in criminal activity, the court can mandate that they attend treatment and will often monitor their compliance in treatment.

But when teens turn 18, getting them into treatment for depression can be a thorny issue, if they are either afraid to get into treatment, they feel stigmatized, or they refuse to participate in treatment as part of their rebellion towards you.

What to Do If Your 18 Year Old Refuses to Get Help:
Recognize that, ultimately, as scary as this might be, in most cases, the decision is up to your 18 year old. But there are some steps that you can take to help your 18 year old to get help:

Normalize What Your Child is Feeling
As previously mentioned, it's not unusual for teens to be depressed. Your 18 year old might feel that he or she is the only one who is going through depression. This can be especially painful because teens often have a strong need to "fit in" with their peer group. If they think that what they're going through is "weird" or "crazy," it would be helpful for them to know that they're not alone.

Provide Your Child with Psychoeducational Material about Depression
Organizations like NAMI ( have websites that provide psychoeducational information about depression. So, even if your 18 year old won't listen to you, he or she might be more receptive to information that is online.

Elicit the Help of Someone Close to Your 18 Year Old
During the adolescent phase of growing up, teens are striving to have some degree of autonomy and control. This often translates into alternating behavior of over dependence and rebellion towards parents and authority figures. An 18 year old's decision not to participate in mental health treatment for depression can be adversely affected by his or her need to feel autonomous and independent from parents. So, even though you might be the one who is most familiar with what's going on with your teen, you might not be the one that he or she will listen to about this. In many cases, it's helpful to find someone who has some influence with your teenager--that might be an older sibling, an aunt or uncle, your child's medical doctor, or a coach. They might be more persuasive than you.

Try Not to Get into a Power Struggle with Your 18 Year Old
If your 18 year old refuses to get help for depression, your inclination might be to feel angry and frustrated. You might see all the signs and symptoms of depression and know that you have better judgment with regard to your teen getting help. However, aside from emergency situations, if you try to force, rather than persuade, your teen to get help, your teen might dig in his or her heels about this, making it less likely that he or she will get help.

What About Suicidal Thoughts, Intention, Plan or Attempt?
If your teen is talking about suicide, you need to consult with a psychiatrist who specializes in working with teens immediately. Teens can be impulsive and events that might seem insignificant to you can often be emotionally overwhelming for a teen. When teens are impulsive, often, there is no forethought about suicide--they make the attempt.

If your teen has actually made an attempt, of course, you need to call 911 immediately. If your 18 year old is taken to the emergency room for a psychiatric evaluation following a suicidal attempt or gesture, the psychiatrists can hold him or her for up to 72 hours or more if they feel that your child will be a risk to him or herself or others.

Hopefully, as a parent of a teen, you will never be faced with adolescent depression in your child. But if you are, aside from getting your teen help, the family might need family counseling and you might need your own psychotherapy to cope with this ordeal.

I am a NYC licensed psychotherapist, hypnotherapist and EMDR therapist who works with individual adults as well as couples.

To find out more about more about me, visit my website:  Josephine Ferraro, LCSW - NYC Psychotherapist

To set up a consultation, call me at (917) 742-2624 or email me

Wednesday, March 10, 2010

Starting Psychotherapy: Developing a Sense of Psychological Mindedness

What is Psychological Mindedness?
Often, for people who are starting psychotherapy for the first time, there is a misconception that the client comes to see the psychotherapist, explains the problem, and the therapist gives the client "the answer" about what to do. This is what's meant by the client who seeks the "quick fix."

Starting Psychotherapy: Developing a Sense of Psychological Mindedness

Aside from certain specific problems. like coming for clinical hypnosis for smoking cessation, generally, there are no "quick fixes" in psychotherapy. There are certain types of psychotherapy that tend to be faster and more effective than regular talk therapy, like EMDR and clinical hypnosis, for certain problems.

But, generally, psychotherapists don't tell their clients what to do. Unlike counseling, where counselors often give advice, in most cases, psychotherapy involves a self exploration of your internal emotional world. And in order to engage in this self exploration of your internal emotional world, you need to begin with a sense of curiosity that allows you to develop psychological mindedness.

When you develop a sense of psychological mindedness, you're more open and curious about your emotional world. Rather than passively waiting for the therapist to tell you what to do, you become actively involved in your own internal process. I emphasize the word "process" because this is not a one-time event. It's a process that usually unfolds over time.

Developing psychological mindedness involves more than just coming to vent about your problems or "report" on what happened in the last week. When you develop a sense of psychological mindedness, you develop an awareness of your thoughts, feelings and behavior.

If you're working with a psychotherapist who emphasizes the mind-body connection, as I do, you also become more aware of where you feel your feelings in your body. Learning to recognize where you feel your feelings in your body can be very powerful. It helps you to develop emotional insight and not just intellectual insight.

The difference between emotional insight and intellectual insight is that when you have emotional insight, you feel it in your "gut." You have a deeper sense of knowing than you would when you only have intellectual insight and it's just ideas in your head.

When you're psychologically minded, your emotional world as well as your external world around you, opens up for you in a new way. You begin to become more aware and make psychological connections in your life that you wouldn't have made if you remained passively waiting for a therapist (or anyone else) to tell you what to do. Generally, you begin to see more readily what you're doing that's not working for you. You also often see what triggers your behavior, whether it's unresolved issues from the past or something that is going on in the here-and-now.

Being psychologically minded and making psychological connections about your internal world and how you interact with others allows you to start making changes, if you're ready and willing to make those changes.

You might wonder why I would say "if you're ready and willing." After all, if you're coming to see a psychotherapist, doesn't that imply that you're having problems and you want to change? Well, not necessarily.

Often, people begin psychotherapy because the discomfort of having certain emotional problems has become overwhelming. They know that they're emotionally overwhelmed and they don't want to feel that way. They want the emotional pain to stop or the problems to end. But actually going through the psychological process of developing curiosity and awareness so they can make changes in their life is not always what they bargained for.

Once again, the desire for the "quick fix" can be strong, and it might be hard to understand why coming to psychotherapy is different than going for a one-time visit to your medical doctor where your doctor diagnoses the problem, tells you what it is, and gives you a pill or an injection to solve it.

Psychological problems are more complex than most regular medical problems. There are often multiple layers of meaning to your thoughts, feelings and behaviors. So, when your therapist listens to the problems that you bring into your session, he or she is not just listening for a list of symptoms and connecting it to a particular illness that can be readily resolved with a prescription.

Developing Psychological Mindedness as a First Step in Psychotherapy:
So, becoming curious and open to your thoughts and feelings as well as your behavior, and learning to make psychological connections between them is the beginning of developing psychological mindedness. It's a much richer and more rewarding process than if someone just tells you what to do (even if there were someone who actually knew what was best for you). It's the beginning of your psychological process in psychotherapy.

Developing a Sense of Psychological Mindedness in Therapy

Why do I say developing psychological mindedness is just the beginning? The answer is that, in order to make changes, in most cases, you need to take action. Most of the time, it's not enough to just be psychologically minded, understand the problems and stop there. Depending upon the problem, you often need to actually do something to make a change.

Getting Stuck After Developing Psychological Understanding and Before Taking Action:
Many clients in psychotherapy get stuck at the point where they need to take action. Developing a psychological understanding of the problem, while being essential, is not the be-all and end-all of the process. Getting stuck before taking action is common obstacle, but it doesn't need to be a permanent state. It can be a stage in the process that needs to be overcome and clients often do overcome these obstacles if they're willing to stick with the process.

Once again, psychological mindedness can help clients to understand why they get stuck before they take action to change their problems. It can be that they're really not ready yet to make the changes they need to make. It can also be a fear of what it might be like to change and have things be different. There can be so many other factors involved.

A skilled psychotherapist can often help clients to translate emotional insight and psychological understanding into action, but the therapist can't do it for them. When a client gets stuck, patience on the part of the client and the therapist is usually helpful. There might be other underlying issues, possibly trauma, that might not be immediately apparent at first to the client or even to the therapist.

If you're seeing a thearpist who is trained in different forms of psychotherapy, it might be necessary to switch from one form of psychotherapy, like regular talk therapy, to EMDR or clinical hypnosis to overcome the particular obstacles or trauma that have arisen which prevent the client from making the change. But that's a different blog post (see my earlier posts that describe EMDR and clinical hypnosis and how they're different from regular talk therapy).

Learning to be a Psychotherapy Client:
Most clients who begin psychotherapy learn how to be psychotherapy clients as they go along with the help of their therapist. Learning to be a psychotherapy client is a learning process in itself because participating in psychotherapy is different from most anything else that you've ever done before. You might have seen movies or TV programs of people in psychotherapy and, even if it's an accurate portrayal of psychotherapy (and it's often not), when it's your personal psychotherapy, you experience it on a very different level.

When you begin psychotherapy, developing a sense of psychological mindedness can be a challenge. But it's often an experience that allows you to know yourself in a deeper and more fulfilling way. Developing a psychological understanding of yourself involves more than just brief treatment. It involves dedication and patience that develops over time.

As I mentioned earlier, there are certain problems (like smoking cessation) that can be overcome in 3-5 sessions. But for most complex problems, even problems are amenable to EMDR and clinical hypnosis, developing psychological understanding is a process that takes time.

About Me
I am a licensed psychotherapist, hypnotherapist and EMDR therapist in NYC.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during regular business hours or email me.

Saturday, March 6, 2010

The Problem with the "Geographic Cure"

In the US, thousands of people relocate to all areas of the country every year. Many people travel to attend college, to start new jobs, to live in a warmer climate, or to seek new opportunities. These are all common reasons for moving.

But among the many thousands of people who move every year, there are many who move to seek the "geographic cure," and who are disappointed when the changes they hoped for don't occur.

What is the "Geographic Cure"?
The "geographic cure" is a term used when people move to another area, hoping that their problems will disappear because they're in a new location. They hope that, by being in a new area, they'll escape their emotional problems. 

The Problem with the "Geographic Cure"

Rather than making internal changes in themselves to change their thoughts, emotions, and behaviors, they think that a change in location is "the answer."

What's the Problem with the "Geographic Cure"?
The most obvious problem is that you can't rely on your external surroundings to overcome your emotional problems. 

Your emotional problems require a search within yourself and the willingness to make the necessary emotional and behavioral changes to overcome your problems. 

Sure, it's possible that you might be more content for a while if you move. A new location can be fun and exciting for a while, and there are plenty of distractions when you're setting up a new household. But after a while, especially if your emotional problems are deep rooted, life will settle into a routine, there won't be as many distractions, and you'll be aware, once again, of the same emotional problems that you were suffering with before.

As the saying goes, "Everywhere you go, there you are."

The following vignette, which is a composite of various clinical cases with all identifying information changed, illustrates why the "geographic cure" doesn't work:

Paula grew up in a small town. Her father was a raging alcoholic and everyone knew him as the "town drunk." Her mother was extremely passive and did whatever she could not to make waves with the father so he wouldn't get upset. 

All Paula could think about, as she was growing up, was that she wanted to move away. Her elementary school teachers recognized that she was depressed and advised Paula's mother to take her to see a mental health professional. But Paula's mother didn't believe in psychotherapy. She was also afraid that her alcoholic husband would be furious because he would think that Paula would be talking about him in her therapy. As a result, Paula never got help as a child.

When she was old enough to go to college, Paula applied to a college on the West Coast, wanting to get as far away from her family as possible. Initially, she was happy to get away from her family and she did well in college. But after the initial excitement of living in a new city wore off, she began to be aware of her depression again. 

She was very intelligent, so she did well in college. But she struggled to just get through the day. She made a couple of close friends in college and they advised her to go to the campus mental health center because they recognized that she was depressed. Paula went to a few counseling sessions, but she dropped out as soon as the counselor began exploring issues regarding her parents. She decided that she would deal with it on her own, and when she graduated, she would move to the East Coast to find a job.

Ten years after Paula graduated from college, she had moved from state to state several times. After college, she moved to NYC and landed a terrific job. At first, she thought she had beat her depression because she was feeling good about her job and visiting all the places in NY that she had always wanted to see. But once life settled down, she couldn't distract herself with the newness of the city any more, and she felt the familiar leaden feeling of depression weighing her down again. From NY, she moved to Chicago, then to Atlanta, Florida, Washington state, New Mexico, Arizona, and then back to NYC.

Each time, she experienced the same thing: She felt better for a while and then she began to feel the depression again when she could no longer distract herself. While she was living in NYC for the second time, a friend spoke to her about the "geographic cure." 

Paula had never heard this expression before. But as she listened to her friend speak, her friend's words resonated with her. She began to realize that all of this moving around, ultimately, didn't change anything for her. After a while, she was aware of her depression again and realized that it never really went away--she was just less aware of it because of all of the distractions of moving.

When Paula began psychotherapy with me, she was at a low point. She had a good job, but all the moving, which was expensive, put a big hole in her savings. At that point, even if she wanted to move again, she couldn't afford it. 

Gradually, over time, Paula began to deal with her depression in therapy. After a while, she began to recognize that she was having some good days, as if something had been lifted from her emotionally. There were days when she didn't have that leaden, depressed feeling that had been weighing her down. And as she continued in therapy, she began having more good days. Her only regret was that she wished she had started therapy years ago.

When you're trying to avoid dealing with your feelings, it's very easy to convince yourself that some external change will be "the answer" to your problems. 

Of course, if you're in an abusive environment, as Paula was when she was growing up, it's a good idea not to remain in that situation if you can get away. 

But, just like Paula, many times the emotional damage has already been done. And while it's important to remove yourself from an abusive environment, it's usually only the start. The emotional fall out has already been internalized and, often, you can't overcome it on your own. You need professional help.

Getting Help in Therapy
Emotional problems need to be dealt with from the inside out. Changing the external environment often doesn't change your emotional problems. The "geographic cure" is a form of denial.

If you've been relying on the "geographic cure" to overcome emotional problems and you recognize a recurring pattern similar to what I've described in the composite vignette, you could benefit from seeing a licensed psychotherapist to deal with your problems. 

When you seek a therapist, make sure that he or she is a licensed mental health professional in your state.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, and EMDR therapist.

I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

The Breakup: When the Need for Closure Turns into Harassment

Breaking up is almost never easy, especially for the person who wants to reconcile the relationship. For many people, there are times when the breakup of their relationship comes as a shock. For those people, who thought their relationship was going well, when they hear their spouses or partners tell them that it's over, the words land on them like a ton of bricks. It seems incomprehensible and unreal--as if they're stuck in a nightmare.

The Breakup: When the Need For Closure Turns into Harassment 

Years later, in hindsight, some people say that there were signs all along that the relationship was not gong well, but they were in denial and didn't see it. 

Many others, even with the benefit of hindsight, say there were no signs that their partners were unhappy. Either way, the end of a relationship can be traumatic, even when it's mutual. 

But when it's not a mutual decision, the person who wants to continue in the relationship often feels abandoned and wants very much to understand what happened and have a sense of closure about the breakup. 

However, the need for closure, especially when the partner who is leaving is not open to further discussion, sometimes leads to desperate attempts (by the partner being left) for a discussion, an explanation, maybe there's even some attempts at bargaining that they'll change whatever the other partner didn't like.

But how do you do you know when you've crossed the line from a need for closure into a form of harassment?

The following is a list of signs that you (or your partner) have crossed the line and are engaging in harassment. There are countless other forms of behavior that would be considered harassment, so this list gives you an idea, but it's not exhaustive:
  • Making endless calls and leaving numerous voicemail messages to your former partner, after s/he told you not to call any more
  • Showing up at your ex's house uninvited (and unwanted) after the breakup to discuss, plead, or argue
  • Calling your ex at his/her job numerous times after you've been asked to stop
  • Showing up at your ex's workplace uninvited (and unwanted) after the breakup
  • Waiting around at places that you know your ex typically frequents in an effort to see your ex or talk when you know your ex doesn't want you there
  • Sending numerous email messages either begging, threatening or arguing about the breakup
  • Threatening to reveal information about your ex to your ex's family, employer, friends or others that you know would be embarrassing, jeopardizing your ex's job or other relationships
  • Divulging confidential information that you know will be harmful to your ex or talking badly about your ex to people who could use the information against your ex
  • Running up credit cards that are in your former partner's name as a form of retaliation for the breakup
  • Damaging your ex's property (this can involve his/her car, home or other possessions)
  • Stalking or following your ex, your ex's family, friends or new partner
  • Calling your ex's relatives, friends, employer or new partner as a form of retaliation
  • Making false police reports against your ex (e.g., making a false report of domestic violence)
  • Making false reports of child abuse regarding your ex to the local bureau of child welfare
Needless to say, any form of violence towards your ex, your ex's family, friends or new partner is considered an assault and it's a crime.

You should be aware that many of the items on the above list are legally actionable, your ex can file a police report against you and, possibly obtain an order of protection. In some cases, you might be arrested, especially if you persist.

Although breaking up is almost never easy, the vast majority of people eventually grieve the loss, accept the breakup and don't engage in harassing behavior. After a period of time and, sometimes, with the help of psychotherapy, most people heal from the heart break and move on with their lives.

But for some people, the breakup can trigger strong emotions, often, of unresolved feelings of abandonment from their family of origin. When this occurs, the anger and sadness can be intense and overwhelming to bear. But this is never an excuse to harass your ex or people close to your ex.

Getting Help in Therapy
If you find that you're stuck in an obsessive cycle of angry thoughts or compulsive or harassing behaviors related to your breakup, you should seek the help of a licensed mental health professional before it's too late. 

Most experienced psychotherapists have dealt with these issues before, and you don't need to feel embarrassed to seek help.

About Me
I am a licensed New York City psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.