Another Tragic Loss

By Melissa Deuter, MD

Philip Seymour Hoffman was found dead over the weekend with a needle in his arm. It’s heartbreakingly ironic to have this incident in the same week when I am scheduled to meet with the local Parents’ Al-Anon group, a collection of parents trying to cope with addicted children. I would like to think that a public tragedy like a famous actor’s death might raise awareness, that after hearing about it, our country would see a dramatic fall in drug use and drug related deaths, but it never seems to work that way. Drug abuse and addiction defy logic, even for users.

Experience treating drug addiction has shown me first hand how the denial of addiction works. An addict in recovery will vacillate between periods of gratitude and clarity, saying things like, “If I had continued using, I would be dead by now.” Philip Seymour Hoffman made a statement similar to that last year in an interview with TMZ while discussing his relapse to addiction after twenty-three years of sobriety.

It has long been recognized that addiction is intertwined with denial. Neuroscientists have studied functional brain scans of individuals who struggle with addiction, noting differences in activity in the brain areas associated with “insight,” the antithesis of denial. The science and the accounts of afflicted users and their families make one thing clear: reasoning with addiction doesn’t work. We can rant until we turn mad, but an addict cannot hear reason. The ranting inflicts shame more often than insight.

So what then are families and professionals left to do?

What works is raising insight before substance use starts, through effective education. That’s not to say that fear tactics, aimed to scare kids into steering clear of drugs, are useful. However, opening kids minds to the truth about pressures they will face related to drug use can help. Discussing the denial, the way a person’s mind can tell him lies, helps too.

Research studies show how love, patience, warmth, and acceptance are vital components to battling drug addiction also. “Secure attachments,” caring bonds with trusted loved-ones, facilitate insight, whereas hurt, shame, and anxiety diminish insight. Families can literally love an addict closer to sobriety.

Beyond education and warmth, slaying addiction is primarily the work of the afflicted user, with loved ones waiting, watching, and offering assistance by facilitating access to treatment and holding addicts accountable for unhealthy behaviors. Al-Anon, the twelve-step program for families of drug abusers, teaches families these vital truths. If prevention efforts fail, even parents learn they must “Let go and let God,” when it comes to addiction.

As our society copes with the news of another untimely death from addiction, I hope we can redouble our efforts to educate and prevent substance use. As honored as I feel to speak at the Al-Anon meeting this week, successful prevention programs may have given these affected families a more joyful way to spend their Wednesday night. 

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.

Are Psychiatrist’s Labeling Healthy Young Adults as Mentally Ill?

By Melissa Deuter, MD

“In a given year, over 40% of U.S. 18 to 29 year-olds meets criteria for psychiatric disorder, a higher rate than for any other adult age group.” -Jesse Viner and Jennifer L. Tanner 

A mental health diagnosis in young adulthood tends to follow a person throughout the adult years. But what if the diagnosis is wrong?

Incapable of taking the necessary steps to find a job or enroll in school, many emerging adults end up in mental health treatment. Some who land in my office don’t really need a psychiatrist. For example, Mark.

Twenty-year-old Mark began diagnosing himself with psychiatric illnesses off the internet. His inertia was depression; his avoidance, social anxiety; his scattered plan, ADD. He could certainly be made to fit checklists of criteria, but Mark didn’t appear mentally ill. With no signs of taking responsibility for himself, I suspected he had more of a complicated failure to launch issue than a mental disorder. He didn’t seem depressed, anxious, or more scattered than average; he just seemed lost.

Mark wasn’t finding work because staying home, in many ways, had proven easier. I wonder if he would be working if he didn’t have a Mom to take care of him.

What is notable to me about Mark (like many of the young adults who are failing to launch) is that he is unhappy and he has the power to change his situation, but he hasn’t taken the necessary steps. He complains of low self-esteem and even shame, yet continues to spend his days on his mom’s sofa playing Xbox instead of making a life plan. He doesn’t research options or apply for jobs. Mark has no experience (yet) with financial or emotional independence. He stays in an unhappy circumstance because, without experience, he doesn’t quite know how to run his own life.

Now almost a year into his young adulthood, Mark feels trapped in a situation he doesn’t like very much. Worse, Mark sees no way out because he has always been completely financially dependent on his parents. When Mark decided to stay with his mom after high school, he expected it would be temporary refuge, and then he would find a terrific job, support himself, and quickly move on. But it hasn’t worked out that way.

I think my profession’s prevailing wisdom is to diagnose and treat, just in case. But what harm could be done if I diagnose Mark with depression, social anxiety, or ADD? What if I lead him to believe he is too ill to work or attend trade school? What if he believes he is sick, and the sickness becomes part of his lasting view of himself? And what if I treat him for a disease he does not have? What about risks and side effects?

Physicians need to talk more about support and education for non-illness problems, and move away from “just in case” diagnosis and treatment, especially for those on the verge of independence—when so much is at stake for a young adult’s future.

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.

Academic Ability ≠ College Success

By Melissa Deuter, MD

Recent reports place the US college drop out rate at around 46 percent. That’s not a typo—46 percent. That means students who enter (and pay for) college in the US successfully complete a degree only 54 percent of the time, a little over half. Experts in educational policy point to the high cost of college, or to academic readiness as the cause for soaring drop-out rates, but as a psychiatrist who specializes in treating college-aged patients, I’m not so sure. When a student is in a crisis of college failure, I am often one of the first numbers the parents dial.

My phone starts ringing two weeks after final exams, when grades arrive in the mail. The messages are from parents of kids with bright futures, flunking college courses. Students might drink too much, hate college and want to quit, or perhaps have no discernible reason for poor grades. One with “no reason” to struggle academically has an appointment with me next week, a young man I have known for two years, and I can guess many of the details now. Let’s call him Evan.

Evan graduated from a prestigious private high school with honors. His SAT scores were through the roof. I saw him for anxiety during his junior and senior years of high school, anxiety brought on by girlfriends and adolescence in general, but he never had any trouble with academics. He was a brilliant student. Straight A’s in a college prep high school, honors and AP classes filled his schedule. Teachers loved him, assignments were turned in on time; he was a great candidate for a dazzling future first as a college student, then later as a professional. Evan and his parents were puzzled by my growing concerns his senior year—I was afraid he was unprepared for college. I raised the issue several times, and it fell on deaf ears. Academically, they knew he was ready. I was worried about his non-academic skills. Eventually his social anxiety subsided and they stopped coming. I didn’t hear from him or his parents until winter break three semesters into college. He was on academic suspension.

The family will come this week, and I will review my concerns raised two years ago. Sure, Evan was a good kid. He was intelligent and cooperative, but he had to be pushed, often pushed hard, to get things done. The first time I met his mother, she called herself a “Tiger-Mom,” apparently uncertain whether she thought it was a good or a bad thing to be. She said the family valued academics, college and post college education, achievement, and personal responsibility. Both parents were high achievers— ambitious perfectionists, both driven to achieve. These were all precisely the reasons for my concern. Kids from families like Evan’s don’t necessarily do well in college, at least not as often as folks believe they will.

Motivation and ambition are hard to instill or measure. They don’t seem to be inherited like eye and hair color. Drive comes from someplace else. Two ambitious parents probably expect to have ambitious kids, but often one or more children of go-getter parents will not be go-getter types. In fact, as a professional, I have come to expect one highly “laid-back” child to be the norm when both parents are ambitious and driven. I have often thought that Family Systems Theory might explain the rate of unmotivated kids from high achiever parents: maybe the family system already has enough ambition, so the child adopts a laid-back stance; the open space in the family system.

When I meet a teen with two driven parents, I look for the signs of this family dynamic. In Evan’s case, his “Tiger Mom’s” constant pushing was a big indicator that he might lack internal drive. Evan didn’t “push” himself. He was propelled by his mom. Also, Evan wasn’t excited about his life or his future. He didn’t get fired-up about anything. He obeyed his parents and tried to stay out of trouble, but when he got to college without his parents, then what would keep him going?

Most college student retention policies focus on academic skills and funding, but how many of the students simply lack the internal drive for college, like Evan? He had the academic skills and the finances for college, and he’s not making it. The social policy makers can’t help Evan, but I hope his parents can. I will advise them to stop steering and give over the reins to Evan. Let him work, ask him to pay rent, and try to leave him space to cultivate a spark of excitement about life. In essence, I will ask them to back off and make room for Evan’s ambition to grow.

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.

The Hazy Line from Teen to Adult

by Melissa Deuter

Have you ever considered that a teenager is a creature designed to leave home? From the outset of adolescence, teens are fearless, restless, and driven to social and sexual exploration. Most parents would agree kids aren’t ready to leave home at thirteen or fifteen—they still have a great deal to learn. Instead of leaving the family at puberty, the standard evolved so that kids started to break away after high school. Eighteen was the line. Over time, parents saw value in extending support even longer and the adulthood line has been getting pushed later. Parents are supporting and supervising kids longer, so kids are taking over financial responsibility well into their twenties and beyond. Today, financial support for adult children can last as long as a decade or more.

When kids progress through early young adulthood without faltering, the new method of moving from childhood to adulthood is perfect. If they attend college, they can live in an in-between world with aspects of childhood (parental help, returning to childhood bedroom on breaks) and aspects of adulthood (living away from home, privacy, running daily lives unsupervised). But when kids cannot get through college as planned, parents often don’t know what to do next.

Who knows where childhood ends and adulthood begins anymore? Parents want adult children living at home to follow rules like children, be grateful and respectful like children, but then to be as responsible as adults. The kids want to be cared-for like children, have the responsibilities of children, but be respected as adults. Everybody ends up disappointed and ultimately having to adjust their expectations. Families today have to make their own rules, there is no blueprint. Since the line between childhood and adulthood is no longer clear-cut, each family must develop a plan, as kids take on adulthood step by step. Parents and kids have to structure a program for support and responsibility so everybody is on the same page.

It surprises me that parents don’t expect more bumps on the path to transitioning a kid into adulthood. It is one of the most complicated times in a person’s life. Think about the long list of tasks a young adult is attempting to master: education, short and long term career, relationships, dating, intimacy (emotional and physical), managing money (paying expenses, saving for the future, and planning for unexpected financial emergencies), cleaning up their own messes, and keeping life organized. Kids might stumble in any of these areas, and it is remarkable that they succeed most of the time. How much time is enough to prepare a child for all he or she will have to do as an adult? Do you have a plan?

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.