Therapy
Feelings are your algorithms and their make-up are like no one else's in the world. They are one of the many things that make you so unique. - Gordon Clay
Texting, Messaging & Chat Compared
The 9 Best Online Therapy Services of 2021 How to Find a Therapist Who Does Not Panic about Suicide
Teen Therapy and Psychiatry Online: Hit or Miss?
Just as They Are: Protecting our children from the harms of conversion therapy. (52 page PDF
Find A
Therapist/Support Group  Psychology Today Therapist and Support Group Finder American Foundation for Suicide Prevention Suicide Bereavement Support Group Finder HelpPRO Suicide Prevention Therapist Finder Emotional Wellbeing During the COVID-19 Outbreak Find a mental health provider - Wild Rivers Coast, Oregon
11 Very Good Reasons
To Go To Therapy - Because there’s nothing wrong with
seeking help. Misconceptions abound about what it means to talk to a mental health professional. The need to talk about your emotions is seen as something to poke fun at, weak or shameful. That stigma is often why people don’t seek help in the first place. But here’s the reality: Therapy is an incredibly useful tool that helps with a range of issues, from anxiety to sleep to relationships to trauma. Research shows that it’s incredibly effective in helping people manage mental health conditions and experts say that it’s worth it even if you don’t have a medical problem. If you still need convincing, here are a few reasons why you should give the practice a try: 1. You’re experiencing unexpected mood swings. If you’re noticing you’ve taken on a more negative mood or thought process ? and it’s persistent ? it might be worth talking to someone. This is typically a sign of a mental health issue. A therapist can help you get to the root of the problem, according to clinical social worker Rachel Fogelberg, who works with the University of Michigan’s department of psychiatry. “You have the opportunity to open up about your thoughts, feelings and circumstances in a confidential environment,” Fogelberg told The Huffington Post. “Within the safety of this secure environment, individuals can feel comfortable to explore areas of themselves or their lives that they are struggling or unhappy with.” 2. You’re undergoing a big change. This could be a new career, a new family or moving to a different city. New ventures are challenging and it’s normal to need assistance with that. “You can work with someone with a neutral perspective to identify goals and to develop a plan to achieve them,” Folgelberg said. “Therapy often involves the development of skills and strategies to reduce or manage life stressors.” 3. You’re having harmful thoughts. Suicide and self-harm are completely preventable with treatment by a licensed professional. If you’re thinking of hurting yourself immediately, seek help right away through the National Suicide Prevention Lifeline (800-273-8255) or the Crisis Text Line. Text SOS to 741741 4. You’re withdrawing from things that used to bring you joy. A loss of motivation could signal that something is up. If you’re normally a social butterfly and you’re suddenly pulling away from your weekly sports league, for example, you could be experiencing something deeper. A therapist is trained to help you uncover why this might occurring, Folgelberg explained. “The truth is, therapy can be very helpful for many people and often helps individuals sustain their mental health,” she said. 5. You’re feeling isolated or alone. Many people who deal with mental health issues feel like they’re singular in dealing with their experience, according to licensed master social worker Nancy McCorry, who works at the University of Michigan’s Addiction Treatment Services. Group therapy could help with this or even just having a medical professional recognizing the validity of your emotions. “When you enter therapy ... you get the immediate sense of relief that you are not alone,” McCorry told HuffPost. “Your problem is well understood and shared by others. This can bring about a sense of both comfort and hope.” 6. You’re using a substance to cope with issues in your life. If you find yourself turning to drugs or alcohol as a way to deal with what’s going on in your life, it might be time to reach out. Addiction and substance abuse are medical conditions ? not character flaws, McCorry stressed. “There have been many breakthroughs in our understanding of the biology of addiction and evidenced based treatment to assist people in achieving their treatment goals,” she said. “Going to therapy allows a person to gain the knowledge needed to fully address their illness.” 7. You suspect you might have a serious mental health condition. Serious mental illness affects almost 10 million adults in America in a given year. If you’ve been feeling off for a long period of time, reach out. Psychiatric conditions like bipolar disorder or schizophrenia rarely develop out of nowhere and people display signs for a while. Symptoms, particularly ones like severe nervousness, apathy or intrusive thoughts, should not be ignored. They’re treatable. 8. You feel like you’ve lost control. This particular feeling arises when people are dealing with a substance abuse or addiction issue, McCorry said. This lack of control often keeps individuals in the in a repetitive circle of substance use. “This can keep a person in the cycle of addiction ? using their substance in order to avoid painful feelings. Going to therapy can help to lift this heavy burden 9. Your relationships feel strained. Relationships ? no matter what kind ? are hard work. You’re not expected to have all the answers. If you’re with a partner, therapy can help the two of you explore better ways to communicate and any other issues that seem to pop up. Couples therapy can even be beneficial if your partner is hesitant and doesn’t end up attending the session. “The therapist can pinpoint how to help the spouse interpret misunderstandings and identify where they’re most at odds,” Debra Campbell, a psychologist and couple’s therapist in Melbourne, Australia, previously told HuffPost. 10. Your sleeping patterns are off. A key symptom of depression includes a disruption in sleep, whether it be too little or too much. If you’ve noticed any significant change, it might be time to investigate the underlying issue (this even goes for insomnia, which also includes therapy as a method of treatment). 11. You just feel like you need to talk to someone. Bottom line: There’s nothing wrong with seeking professional help for any health issue, including mental health. To put it as actress Kerry Washington once did, “I go to the dentist. So why wouldn’t I go to a shrink?” If you have an inclination that you
might need to speak with someone, do it. Therapy is a
perfectly normal ? and valuable ? experience that works to
many people’s benefit. Guide to Mental
Health Specialists List of Specialists In the Who Can Help With Diagnosis and Who Can Help With Treatment sections of our Parents Guide to Getting Good Care, we walk you through the kinds of mental health professionals who might be helpful in various situations. Here we go through the list of specialists and focus on what their areas of expertise are, how they are trained and licensed, and what services they offer. Psychiatrist: A psychiatrist is a medical doctor, or MD, who is trained to diagnose and treat psychiatric disorders. General psychiatrists treat adults but some choose to diagnose and treat children with psychiatric disorders as well, including prescribing medication, and psychotherapy. General psychiatrists are fully qualified if they have completed national examinations that make them “board certified” in general psychiatry. Child and Adolescent Psychiatrist: Child and adolescent psychiatrists are MDs who are fully trained in general psychiatry and then have at least 2 more years of training focused solely on psychiatric disorders arising in childhood and adolescence, including developmental disorders. Child and adolescent psychiatrists are skilled at diagnosis, prescribing medication, and psychotherapy. The American Academy of Child and Adolescent Psychiatrists (AACAP) allows parents to search its members with its psychiatrist finder. Child and adolescent psychiatrists are fully qualified if they have completed national examinations that make them “board certified” in child and adolescent psychiatry as well as general psychiatry. Psychopharmacologist: A psychopharmacologist is a medical doctor who specializes in the use of psychoactive medications in order to affect mood, feelings, cognition, and behavior. A psychopharmacologist is a psychiatrist who focuses on the use of medications in treating psychiatric disorders, but he should know when other kinds of therapy should be integrated with medication in the treatment plan, and be able to either offer it or refer patients to other professionals for that therapy. Pediatric Psychopharmacologist: A pediatric psychopharmacologist is a child and adolescent psychiatrist who has extra training, skills and experience in the use of medication in the treatment of children and adolescents with psychiatric disorders. Most often, this will not be the only form of treatment recommended for a patient, and this clinician will either provide that additional treatment or else refer and coordinate that additional care. Psychologist: Psychologists are trained to diagnose and treat psychiatric disorders, but they are not medical doctors (MDs) so they cannot prescribe medication. A psychologist usually has a doctoral level degree and may hold either a PhD or a PsyD. During the course of psychology training, a psychologist may specialize in a particular area such as child psychology. After completing the doctorate, a child psychologist does at least one year of supervised clinical work or “internship,” in order to qualify for licensure; this may or may not be in a child mental health setting. The most highly trained psychologists do additional post-doctoral training in their area of specialization. Psychologists who have passed national proficiency exams are certified by the American Board of Professional Psychologists or “ABPP.” Psychologists with PhDs do graduate training for 5-8 years in both clinical psychology and research. They are trained as both scientists and clinicians, and are often involved in clinical studies. Psychologists with a PsyD generally complete 4 years of graduate training focused on clinical techniques, including testing and treatment. The American Psychological Association (APA) maintains a database of members. You can narrow your search by the ages each practitioner serves and her area of expertise. Psychologists may utilize several forms of cognitive behavioral therapy tailored to specific disorders, such as exposure and response prevention for OCD, and parent-child interaction therapy for disruptive behavior disorders. Because these treatments involve evidence-tested techniques, it’s important to make sure the practitioner you choose has training and experience with the treatment she is recommending. Psychiatrists and psychologists often work together to provide care to patients who benefit from a combination of medication and cognitive behavioral therapy. Neuropsychologist: Neuropsychologists are psychologists who specialize in the functioning of the brain and how it relates to behavior and cognitive ability. Most have completed post-doctoral training in neuropsychology. They may have either a PhD or a PsyD. Pediatric neuropsychologists have done post-doctoral training in testing and evaluation. They perform neuropsychological assessments, which measure a child’s strengths and weaknesses over a broad range of cognitive tasks, and they provide parents with a report that highlights those cognitive strengths and weakness, and forms the basis for developing a treatment plan. The report also serves as evidence for requesting school accommodations, and as a baseline for measuring whether interventions are effective. Neuropsychologists also work one-on-one with children struggling in school, to help them devise learning strategies to build on their strengths and compensate for their weaknesses. Neuropsychologists who have passed national proficiency exams are certified by the American Board of Professional Psychologists-Neuropsychology or “ABPP-N.” The American Association of Clinical Neuropsychology maintains a list of members. School Psychologist: School psychologists are trained in psychology and education and receive a Specialist in School Psychology (SSP) degree. They can identify learning and behavior problems, evaluate students for special education services, and support social, emotional, and behavioral health. The National Association of School Psychologists has more information. Social Worker: A licensed clinical social worker (LCSW) has a master’s degree in social work and is licensed by state agencies. LCSW’s are required to have significant supervised training and expertise in clinical psychotherapy. LCSW’s do not prescribe medication, but often work with the family and the treating physician to coordinate care. In a school setting, they often offer support for children with behavioral issues and the teachers who work with them. The National Association of Social Workers provides tools for locating help. (Note: Page not working.) Counselor: A licensed professional counselor (LPC) is a graduate level (master’s, education specialist, or doctoral degree) mental health service provider who works with individuals, families and groups in treating emotional and behavioral problems. Counselors are trained to evaluate, diagnose, develop treatment plans and offer therapeutic services. In school settings counselors are often the first to be alerted to student mental health and/or learning challenges and are often the central point of contact for school staff involved in an individual case. The American Counseling Association has more information. Psychotherapist: This is a term used loosely to describe someone who practices some form of talk therapy for mental illness. Psychiatrists, psychologists, and social workers all use the term psychotherapy to describe what they do. But since “psychotherapist” is a self-designated term, not everyone who is called a “psychotherapist” or “therapist” is credentialed, has relevant experience, or is even trained in their stated area of work. If you’re considering seeing someone who is labeled as a psychotherapist, make sure to ask what training he had, whether he is licensed, and what kind of treatment he offers. Pediatrician: Pediatricians are physicians who specialize in treating children and adolescents. They have 3 years of training after medical school and are typically the first professional a parent consults when concerned that a child may have a psychiatric or learning problem. As medical doctors, pediatricians are allowed to prescribe all medications, but they may have little or no training in psychiatric disorders, and limited experience with psychotropic medications. They may also have inadequate time to spend with each patient to do careful diagnostic assessment and regular monitoring of a child’s progress. Some pediatricians practice in networks that enable them to consult with a specialist or invite a specialist to take over a child’s treatment. Parents who are not comfortable with the care available from their pediatrician (or whose pediatrician is not comfortable treating their child) should seek out a specialist—if medication is involved, a child and adolescent psychiatrist. Pediatricians also do medical testing that can be important in ruling out possible non-psychiatric causes of troubling symptoms. Developmental and behavioral pediatricians: Developmental and behavioral pediatricians are pediatric sub-specialists who have completed 2 additional years of training in evaluating and treating developmental and behavioral problems, and hence may offer both more expertise and more experience than a general pediatrician when it comes to children with developmental disorders, though they may not have training in psychiatry and expertise in psychotropic medications. The Society for Developmental and Behavioral Pediatrics has a list of clinicians. Neurologist: A neurologist is a medical doctor who specializes in disorders of the nervous system—which, of course, includes the brain. Neurologists can identify nervous system causes of some worrying symptoms and aid in the treatment of neurological and neurodevelopmental disorders including cerebral palsy and epilepsy. Pediatric Neurologist: Child neurologists complete 5 years of training and clinical experience in pediatrics and pediatric neurology after medical school. Pediatric neurologists specialize in the treatment of neurodevelopmental disorders, including intellectual disability, Tourette’s, ADHD, and learning disabilities. The Child Neurology Society maintains an online resource. Pediatric Psychiatric Nurse
Practitioner: Nurse practitioners have advanced degrees,
either a master’s or a doctorate, and can prescribe
medication. A pediatric psychiatric nurse practitioner has
training in treating and monitoring children and adolescents
with psychiatric disorders. Some work as part of a team in a
pediatricians’ office; some practice independently. The
American
Academy of Nurse Practitioners
has a tool for locating its membership. Parents Guide to
Getting Good Care Does My Child Need Help? We all worry about our kids. Sometimes our worries are about whether they are developing in a healthy way. (Should he be talking by now?) Or about whether they are happy—we don’t like to see them sad or suffering. And sometimes we worry because a child’s behavior is causing problems for him—or for the whole family. One of the challenges of parenting is knowing when a worry should prompt action. How do you know when to get help for a child who is struggling? Keep in mind that there is a lot of variation in how kids develop, and a broad range of behavior that’s typical and healthy (if sometimes troublesome) as children grow up. So you don’t want to overreact. But when the behaviors you worry about are seriously interfering with your child’s ability to do things that are age-appropriate, or your family’s ability to be comfortable and nurturing, it’s important to get help. Here are some things mental health practitioners recommend you consider in deciding whether a child needs professional help. 1. What are the behaviors that are worrying you? To evaluate your situation clearly, it’s important to observe and record specifically the things you are concerned about. Try to avoid generalizations like “He’s acting up all the time!” or “She’s uncooperative.” Think about specific behaviors, like “His teacher complains that he can’t wait for his turn to speak,” or “He gets upset when asked to stop one activity and start another,” or “She cries and is inconsolable when her mother leaves the room.” 2. How often does it happen? If your child seems sad or despondent, is that occurring once a week, or most of the time? If he is having tantrums, when do they occur? How long do they last? Since many problematic behaviors—fears, impulsiveness, irritability, defiance, angst—are behaviors that all children occasionally exhibit, duration and intensity are often key to identifying a disorder. 3. Are these behaviors outside the typical range for his age? Since children and teenagers exhibit a wide range of behaviors, it can be challenging to separate normal acting up, or normal anxiety, from a serious problem. It’s often useful to share your observations with a professional who sees a lot of children—a teacher, school psychologist, or pediatrician, for instance—to get a perspective on whether your child’s behaviors fall outside of the typical range for his age group. Is he more fearful, more disobedient, more prone to tantrums, than many other children? (See our Parents Guide to Developmental Milestones for children five and under.) 4. How long has it been going on? Problematic behavior that’s been happening for a few days or even a few weeks is often a response to a stressful event, and something that will disappear over time. Part of diagnosing a child is eliminating things that are short-term responses, and probably don’t require intervention. 5. How much are they interfering with his life? Perhaps the biggest determinant of whether your child needs help is whether his symptoms and behaviors are getting in the way of his doing age-appropriate things. Is it disrupting the family and causing conflict at home? Is it causing him difficulty at school, or difficulty getting along with friends? If a child is unable to do things he wants to do, or take pleasure in many things his peers enjoy, or get along with teachers, family members and friends, he may need help. Where to Go for Diagnosis Help If you’ve determined that your child’s behaviors, thoughts, or emotions might call for attention, your next move is to consult a professional. But where should you go? A potentially bewildering range of mental health providers are out there, and not all of them are the best people to go to for an evidence-based assessment and sound diagnosis. Where to start depends on the makeup of your child’s current healthcare team and the services available in your area. Not all of the specialists below will deliver a diagnosis, but many of them (pediatrician, school psychologist) can be valuable in the process of getting an accurate diagnosis that will help your child. (See our Guide to Mental Health Specialists for information about the types of specialists who treat children, their training and the kind of services they provide.) Where do I start? For most parents, consulting your family doctor is the first step. While medical doctors are not required to have substantial training in mental health, many do diagnose and treat psychiatric disorders, and others may be able to refer you to a specialist who can. The advantage to going to the pediatrician is that she already knows your child and your family, and she sees so many children, she can be adept at recognizing when behavior is beyond the typical range. She can also do medical testing to rule out possible non-psychiatric causes of troubling symptoms. The disadvantage is that your pediatrician may have limited experience in diagnosing psychiatric and developmental disorders and most don’t have time to do the kind of careful assessment that is important for an accurate diagnosis, given that many common problem behaviors in children—i.e. inattention, tantrums, disruptive behavior—can be caused by several different psychiatric or developmental disorders. Best practices in diagnosing children include using rating scales to get an objective take on symptoms, and collecting information from multiple sources, including the child, the parents, caregivers, teachers, and other adults. (Effective diagnosis of very young children requires extra measures, discussed here.) You should be upfront with your doctor and ask if she is comfortable and knowledgeable concerning mental illness. Ask for a referral or seek out another clinician if you are not comfortable with what your doctor offers.
What questions should I ask about diagnosis? When looking for a mental health specialist to provide a diagnostic evaluation for your child, you’ll want to be prepared with questions that will help you decide if a particular clinician is a good match for your needs:
What if there are no mental health specialists in the area? It is a frustrating fact for far too many families in this country that adequate mental health services are not readily, or even realistically available. This is one reason that so much of the burden of caring for children with psychiatric and learning disorders has fallen to primary care doctors, even if their training isn’t always adequate for a child’s needs, especially in complex cases. Luckily, many state health services have begun to address this problem through telepsychiatry—giving local family doctors access to consultation with trained psychiatrists via telephone or internet. If you are having trouble finding someone competent to evaluate and perhaps diagnose your child, ask your pediatrician or any mental health provider you are in contact with if they can research getting a consultation from a remote service. If that is not available, it may be well worth the time and effort to go to an appropriate center some distance away to get an excellent evaluation and treatment plan that can be taken back for implementation by clinicians closer to home. What Should I Look for in Diagnosis? There are no blood tests or the like for psychiatric and learning disorders, so the diagnosis depends on a detailed picture of a child’s moods, behaviors, test results, etc. So a clinician depends on the information she gets from the child, parents, teachers, and other adults who have knowledge of him. A good clinician will ask you detailed questions about your child’s behavior, diagnosis symptoms, as well as her developmental history and your family’s history. She will also use tools designed to help get an objective take on those behaviors and symptoms. Some of these tools take the form of structured interviews, in which a clinician asks a set of specific questions about a child’s behavior. The clinician’s questions are based on the criteria for each psychiatric disorder in the Diagnostic and Statistical Manual, adapted for children. The answers are then used to determine if the child meets the criteria for a particular disorder. For instance, a clinician might use something referred to as ADIS (Anxiety Disorders Interview Schedule), or the K-SADS (Kiddie Schedule for Affective Disorders and Schizophrenia) to determine whether a child should be diagnosed with one or more psychiatric disorders. Some of the tools used to aid in diagnosis help are rating scales, in which the child is rated numerically on a list of symptoms. For instance, BASC (Behavior Assessment System for Children) is a set of questions that are customized for parents, teachers, and the patient, to utilize multiple perspectives to help understand the behaviors and emotions of children and adolescents. While this scale is not used as a diagnostic tool, it can alert clinicians to areas that are elevated (anxiety, conduct problems, depression) which may indicate that further exploration of a specific area is necessary. For children who may have ADHD, tools commonly used include the SNAP rating scale for teachers and parents, which scores kids on how often each of a list of a 18 symptoms occur. On the other hand, the CPT (Continuous Performance Test), which rates a child’s ability to complete a boring and repetitive task over a period of time, is the gold standard for differentiating kids whose inattention is a symptom of ADHD rather than some other cause, such as anxiety. A-DOS (the Autism Diagnostic Observation Schedule) is a set of tasks that involve interaction between the tester and the child which are designed to diagnose autism. These are just some examples of the kinds of tools qualified diagnosticians use to identify disorders. Most important: Do not accept treatment from a clinician who does not offer a diagnosis for your child. Just as a headache can be caused by many different things, worrisome behavior or moods can be symptoms of a range of psychiatric and developmental disorders. It’s a mistake to try medications to see if they work on the symptoms without a diagnosis that’s clearly explained to you, and based on substantial evidence. What are some questions I should ask? When looking for a mental health specialist to provide an evaluation for your child, you’ll want to be prepared with questions that will help you decide if a particular clinician is a good match for your needs:
Who Can Assist With Treatment? Once you have a diagnosis for your child, it’s time to think about treatment options. In some cases the clinician who did the diagnosis will be a good choice for treatment; in other cases you will need to find a different kind of practitioner. Either way, your primary care practitioner or the diagnosing clinician can be a good place to start the search. A licensed clinical social worker at your child’s school or a mental health facility may play a key role in coordinating care for your child and linking you with other professionals on the treatment team. Through ongoing monitoring, the LCSW helps you evaluate your child’s progress, access necessary services, and address issues as they develop. Before you decide who to work with, get informed. You’ll want to find out what the first-line treatment recommendations are for your child’s disorder, and make sure that the clinician you choose has both training and experience in that treatment. For instance, for many anxiety and mood disorders, there are very specific kinds of behavioral therapies tailored to specific disorders. (For a list of such evidence-based therapies and what they are used for, see our Guide to Behavioral Treatments.) The techniques are not interchangeable: The right clinician for you will be one who has experience in the particular therapy your child needs. If your child would benefit from medication, it’s crucial that you ask if your primary care doctor or psychiatrist who prescribes it actually has experience with that type of medication. Success with psychotropic medications depends on the right dosage, which can take considerable effort to establish, as well as expert monitoring as a child changes and grows. This process takes time and patience; if your doctor is too busy to work with you until the medication is successful, and to monitor your child to see that it stays successful, you should look for another practitioner. Please know that, in many cases, treating psychiatric disorders may begin with behavioral or environmental interventions, before medications. However, only a skilled clinician can properly explain the order in which treatments should be started and continued. Above all, you want to work with professionals who communicate effectively with you, explain clearly what they are offering, listen to your concerns, answer your questions, and pay close attention to your child’s particular needs and behaviors. Here are some specific examples of the kinds of professionals who may help in treatment for your child: Learning disorders like dyslexia: If you’ve had a neuropsychological evaluation of your child, and his learning challenges have been identified, you will want to find professionals who can help him build on his strengths and compensate for his weaknesses. He may qualify for an IEP (Individualized Education Plan), which spells out the support the school district is obligated to provide. In addition to whatever help is provided by school-based professionals, you may want to enlist a learning specialist (or educational therapist), who works with a child to build skills and devise strategies for learning in whatever way works best for him. If he needs help with reading or math-related skills, there are specialists who work on those areas. If he is weak in executive functions, the specialist works with him to structure his time and keep track of the schoolwork he needs to do. Sometimes a tutor is useful for a student weak in a particular subject area, and a homework helper can help an unfocused or disorganized student stay on top of his work. If he qualifies for an IEP, it will outline the support the school district is obligated to give him. Though navigating the world of IEP negotiations can be difficult, the Individuals with Disabilities Education Act (IDEA) is firm on the provision of accommodations to children who qualify. If these cannot be provided at your child’s school, it is within your rights to find them elsewhere. Mood disorders like anxiety or depression: For children with anxiety disorders, such as social anxiety disorder or separation anxiety, the first-line treatment is usually behavior therapy. A psychologist works with both the child and the parents using a treatment protocol that is evidence-tested for his specific disorder. OCD and disorders related to it may be managed in a similar fashion. If a child is anxious or depressed enough to need medication, usually in addition to the behavior therapy, a psychiatrist or pediatrician prescribes medication and works with the child’s psychologist to monitor his progress. It’s important to make sure that whoever is doing the prescribing has experience with the medication and children similar to yours, and enough time to work with you to manage it successfully. Since behavior therapy uses very specific techniques that are not necessarily intuitive, it’s important that your psychologist be trained and experienced in the particular therapy that’s appropriate for your child. More often than not, evidence-based behavior or cognitive behavior therapies are manualized and time-limited—that is, procedures are spelled out very specifically—so a therapist should be able to explain clearly what will be expected of both you and your child, and the duration of treatment. Developmental disorders like autism: For children diagnosed with autism spectrum disorder, treatment usually begins as early as possible with applied behavior therapy, to help kids build social and communication skills that they’re not developing naturally. Psychologists with training in behavior therapy (including ABA ) will usually work with children and teach parents how to continue the therapy in between sessions. Children with autism or developmental delays often work with occupational therapists or physical therapists to build motor skills that are lacking. Children with developmental disorders, including autism, often have sensory processing challenges, which cause them to be unusually sensitive to sounds, lights, and other stimuli, or be under-stimulated by their senses. Sensory problems can be severe, when kids are so overwhelmed or disoriented that they can’t function, try to flee, or have alarming meltdowns. They may benefit from behavioral therapy and some children also work with an occupational therapist on these issues. ADHD and behavior disorders: If your child has been diagnosed with moderate to severe ADHD, the first-line treatment is usually stimulant medication. A psychiatrist or pediatrician can prescribe and monitor the medication. It’s crucial that your doctor has expertise and experience with these medications; getting the right dosage and medication schedule, adjusting the dosage and reevaluating the medication as the child grows and changes are critical to its success. Stimulant medication is fast acting, but there are many kinds, each with different durations and delivery systems, and it may take time to find the medication plan that’s most effective for your child. It’s not unusual for children to change dosage and medications over time, so a close alliance with your clinician is crucial for success. For children with ADHD, behavior therapy generally does not affect the inattention, impulsivity, and hyperactivity symptoms, but it can be very helpful in teaching parents and children how to manage them more successfully. Behavioral treatments with a trained psychologist like Parent-Child Interaction Therapy (PCIT), Parent Management Training (PMT) and Positive Parenting Program (Triple P) help families of kids with ADHD. Parents learn to exercise authority and set limits in a calm, positive way; kids learn to rein in their own behavior more effectively. For children with disruptive behavior disorders, these behavior therapies, with an appropriately trained psychologist, can be very helpful. Sometimes behavior therapy is combined with medication, prescribed by a psychiatrist or pediatrician. Pre-Treatment Questions to Ask Your Doctor Before your child begins treatment of any kind you should ask:
Questions for someone prescribing medication:
Questions for someone recommending behavioral therapy:
How Do I Know if I’m Getting Good Treatment? Treatments that can be effective for psychiatric and learning disorders vary widely, and no two children’s needs are exactly alike. But there are some general standards and questions to ask your doctor to determine whether the care your child is getting follows best practices, whether the treatment involves behavioral therapy, medication, or both.
What if My Child Has Multiple Disorders? One reality that can make treating a child with mental illness particularly challenging is that the symptoms she is experiencing may come from multiple disorders. A child who has autism can also have ADHD; a teenager who has social anxiety can also be depressed. When a child has what clinicians call “coexisting” disorders, treating one will not make the other go away. For instance, if a teenager who has ADHD or depression uses alcohol to self-medicate, and develops a substance abuse disorder, treating the original disorder will not cure the substance abuse. When children have more than one disorder, it’s important to work with a clinician, or a team of clinicians, who can understand how the childhood disorders interact, and come up with a treatment plan that responds to each of them. It’s especially important that any clinician who is prescribing medication be aware of all the coexisting disorders, all the medications that are being prescribed, and how they interact. What About Problems With Diagnosis or Treatment? Like all other areas of medicine, some psychiatric and learning disorders are harder to diagnose, and harder to treat, than others. Since there are no blood tests to determine if a child has ADHD or OCD, clinicians depend on measures of behavior. And many behaviors can point to a number of different underlying disorders. If a child is having trouble concentrating in school, for instance, he could have ADHD, but he could also be very anxious. Add to this the fact that some children have multiple disorders—autism and ADHD for instance, or anxiety and depression. All of this contributes to the fact that sometimes the first diagnosis you get is not accurate, and the first treatment is not always effective. How do you know when it’s time to look for a second opinion, and/or pursue different treatment options? When should I get a second opinion from another clinician? 1. If you have poor communication with your clinician, leaving you feeling that you don’t understand the diagnosis or the treatment, or that he or she doesn’t listen to your concerns or answer your questions, you need to find an alternative. It’s important for your child that you and the professionals you engage are all part of a unified treatment team. 2. If your child—especially your teenager—doesn’t have a comfortable relationship with his clinician, and good communication, it can seriously undermine his treatment. If he’s not willing or able to report his feelings and experiences, the clinician can’t effectively tailor the response. 3. If the clinician doesn’t seem to have enough expertise and experience with the diagnosis and especially the specific treatment he or she has proposed, you may need to make a change. Behavioral therapies like exposure and response prevention (for OCD) or habit reversal (for Tourette’s) or dialectical behavioral therapy (for self-injury) are very precise, evidence-based treatment, and vague approximations don’t work. Similarly, medications are best prescribed by a clinician who has substantial experience with effective dosing, managing side effects, and adjusting over the long term. 4. If the clinician proposes medication for your child without giving you a clear diagnosis, you should look elsewhere. Trying medications to see if they work, without a comprehensive evaluation, can lead to inappropriate and ineffective treatment. Response to medication is NOT a diagnostic tool, so someone is wrong if he says, “Let’s see if this works as it will confirm the diagnosis.” 5. If your child is struggling and your clinician is adding one medication after another, it’s easy to lose track of what’s effective and what’s not. When kids are given medications to alleviate side effects of other medications, it may be time to get a second opinion. 6. If your child isn’t responding to treatment, it may mean that the diagnosis was wrong, and you need to seek a new, broader evaluation. It could also mean that there are several disorders involved, and they need to be identified and treated separately. When should I consider switching to different medication, or adding medication? 1. If the medication your child is on is not alleviating his symptoms, the first step is to make sure that you’ve given it enough time to work—some kick in more quickly than others. You also want to make sure that your clinician has tried adjusting the dosage. Sometimes it takes time to get the dosage up to a clinically effective level. If you’ve done those things and you’re not seeing results that work for your child, it may be time to investigate other alternatives. 2. If the medication your child is taking has side effects that are debilitating, the first thing to do is to make sure the dosage is appropriate. If that doesn’t solve the problem, you should look into other options. 3. Adding medications is something clinicians should do with great care. It’s not unusual for children to take two or more medications, because it’s common for children to have several disorders: for instance, kids with ADHD may have anxiety or depression. You want an experienced clinician with clear expertise if you are combining medications, and it’s generally not a good idea to add medications to counter side effects of the first one. What if my child resists the treatment, or the therapist? 1. You may need to try several therapists before you find one with the right personality to bond with your child or teenager—someone with an active and engaging style that will give your child confidence in treatment. 2. Sometimes when kids are dismissive or negative about the value of therapy it is a result of a mood disorder: the pervasive pessimism and lack of enthusiasm he’s feeling may extend to the possibility of working to get better. In that case the first step in treatment is getting him to identify his pessimism and recognize that it is part of his disorder, and that he can feel better. 3. With anxiety and disruptive behavior disorders that can be appropriately treated with behavioral therapy, it is sometimes necessary to combine a course of medication to decrease your child’s symptoms enough to enable him to participate effectively in the therapy that can make a big difference in his life. 4. It may also be useful to explore something called “motivational interviewing,” a treatment that’s usually applied to substance abuse. Motivational interviewing is based on meeting a patient where he is in terms of his own self-assessment, and working to help him understand how changing problem behaviors might benefit him. What About Alternative Treatment Options? Parents are rightfully cautious about getting treatment for children with mental health problems, especially if that treatment involves a psychotropic medication. Alternative treatments such as specialized diets (for example, avoiding sugar or food dye) and natural remedies or supplements can seem like a good solution if you are seeking treatment that feels safe, natural, and DIY. However, parents exploring these options should be careful because there is very little data showing that most alternative treatments are actually helpful. Anecdotal evidence isn’t the same as scientific testing, and some alternative treatments, like chelation, are even potentially dangerous. Time spent exploring non-evidence-based care may seem like a good investment, but it comes with an “opportunity cost” to your child. That is, the longer kids miss out on treatment that really affects symptoms the more time they’ll spend impaired, and in many cases missing out on crucial learning and development that goes on during childhood and adolescence. Their disorder may also grow worse without intervention. For many disorders, the longer a child experiences the symptoms, the more challenging it is to treat. For some, particularly autism, some interventions should be undertaken early. Before trying an alternative treatment, discuss it with your child’s doctor. As with any treatment, ask a lot of questions. Learn how it works, what evidence supports it, when you should start seeing progress, and if there are any dangers associated. If you aren’t satisfied with the results of any treatment, make an appointment to discuss other options with your doctor or with another professional who can give a second opinion. Supplementing Treatment While not a treatment by itself, promoting good self-esteem and a healthy lifestyle is important for all kids with psychiatric disorders. Exercise makes us feel good, and it can make a big difference for kids who are feeling badly about themselves or have lots of energy. Things that promote self-awareness and relaxed reflection, like mindfulness meditation and yoga, are also generally beneficial. What Should I Do if My Child Has Learning Issues? If you notice that your child is struggling in school, or doesn’t seem to be picking up basic reading, writing, and math skills the way other kids do, he may have a learning disability. A learning disability is a kind of cognitive disorder that affects basic processes in how we learn, including how we receive, process, recall, and communicate information. The most common one is dyslexia (reading problems), but learning disabilities can also affect how we write, spell, do math, listen, think, and speak. It’s possible for kids to have more than one. If you suspect your child may have learning difficulties, make a list of everything you have observed about how he learns—his strengths and his weaknesses. Compare notes with his teacher, school psychologist, and anyone else who might be helpful. You may want to ask for what’s called a “pre-referral intervention”—a meeting where teachers and the school psychologist meet with you to discuss different educational supports that might enable your child to learn more effectively. A targeted remediation may be all your child needs. But if the pre-referral intervention doesn’t give you the results you want, a formal diagnostic evaluation is the next step. How do I get an evaluation for learning issues? Formal evaluations examine how your child processes information. There are different kinds of evaluations, including educational evaluations (which assess reading, writing, math, and spelling ability) and neuropsychological evaluations (which develop a wide profile of a child’s skills and abilities in reasoning, learning, memory, visual and auditory processing, listening comprehension, verbal expression, executive functioning skills, and academic abilities). Evaluations also establish a baseline for measuring your child’s progress, and they are a necessary step to qualifying for accommodations or special education services. Schools are legally required to provide an evaluation according to the Individuals with Disabilities Education Act (IDEA). The school might be the first to suggest an evaluation, or you can begin the process yourself by requesting an evaluation in writing. Understood.org has a sample letter you can use. After receiving your written notice, the school will set up a time to discuss an evaluation with you. You should bring your child’s school records, notes from teachers, and your own written observations to the meeting, and come prepared to discuss them. The school staff is required to share with you the kind of evaluation they feel is appropriate, and you have the right to object to the kind of assessment offered, or request a different one. You will ultimately need to sign a consent form before the school is allowed to perform a formal evaluation. After the evaluation the school is required to give you a copy of the results. If you prefer, you can also get a private evaluation from outside the school, although you will need to pay for it yourself. You can then choose whether or not to share the results with the school. How Do I Get School Services for My Child? Schools will use evaluation results to determine if your child is eligible for accommodations in school or special education services. Students may qualify for a wide range of supports organized under either a Section 504 accommodations plan or an Individual Education Program (IEP). Most states have a Parent Training and Information Center that can help you with any questions you may have about the laws in your state. Section 504 A Section 504 plan provides kids who have learning disabilities with “reasonable accommodations” that allow them to participate in the general curriculum at school. Section 504 is part of the Rehabilitation Act of 1973, a civil rights law that prevents discrimination against any person with a disability at an institution that receives federal funding, including schools and colleges. To qualify under Section 504 your child must demonstrate that she has a disability that substantially limits her in one or more “major life activity.” This might include speaking, listening, concentrating, reading, or writing. Children who do not qualify for services under the Individuals with Disabilities Education Act (IDEA) may qualify under Section 504. Depending on your child’s needs, her Section 504 plan could entitle her to a wide range of accommodations, such as special seating, a quiet place for testing, extra breaks, the use of a computer, different text books, different testing formats, and much more. All appropriate accommodations will be established at the 504 Planning Meeting, which you should attend, as well as any subsequent periodic reviews. Learn more about 504 plans from the National Center for Learning Disabilities. What is an IEP: Individual Education Program Students can get an Individual Education Program (IEP) if they qualify under the Individuals with Disabilities Education Act, a federal law that promises a “free and appropriate education” to children classified with various specific legal disabilities. Categories of disability under IDEA include:
All children who qualify can receive assistance through their local public school district, including those who attend private or parochial schools. To set up an IEP you will attend a
meeting with representatives from the school district
(teacher, special education teacher, school psychologist,
appropriate specialists, etc) to plan
an education program that suits your child’s unique
needs. This will involve
setting specific measurable goals for what you would like
your child to accomplish (e.g. reading X number of words a
minute) and whatever special education services or
accommodations she needs to accomplish those goals. An IEP
might include specially trained educators, special teaching
methods, accommodations like extra testing time, and
whatever else is considered appropriate. You are free to
bring an advocate, private learning specialist, or special
education attorney with you to the meeting or consult with
them before signing off on the IEP. The plan must be
reviewed at least once a year, although you can request to
do it more frequently. Learn more
about IEPs at Understood.org. Why
Aren’t Psychologists Taught How to Prevent Suicides?
April 1, 2018 Every 11.7 minutes in the U.S., a person takes his or her own life. (72% of the time it's a man) That figure, the latest available, makes suicide the 10th leading cause of death in this country. Rates have been rising every year for the past dozen years. It's nothing short of an epidemic. (When the CDC breaks up the major categories like Cancer into individual cancers and then ranks the leading 50 causes of death, Oregon has four of seven age categories, 15-54, where suicide is the leading cause of death. Yet those most well placed to stop this public health crisis are not equipped to do so: few doctors and less than half of U.S. mental health professionals are trained in suicide prevention. According to a recent report from the American Association of Suicidology (AAS), only 50 percent of psychology training programs, fewer than a quarter of social work programs, 6 percent of marriage and family therapy programs, and 2 percent of counselor education programs teach their students how to spot individuals at risk for suicide and how to stop them from going through with it. To get people through such a crisis, experts now have several methods available that have proved effective. Treatments focus on teaching patients how to identify and regulate their emotions and to learn to bear the feeling of distress. It's critical for those at risk to have a plan in place and to practice skills for calming themselves when suicidal thoughts return. Although most therapies involve weeks or months of sessions, even short interventions can work at a moment of crisis. One study, for instance, found that even a single session with a therapist trained in “crisis response planning,” which helps patients identify their own warning signs and come up with coping strategies, reduced suicide attempts in soldiers by 76 percent compared with other treatment methods. “A lot of people hold fast to the old adage: if someone wants to kill themselves, they'll find a way. But it's not true,” says psychologist William Schmitz, Jr., lead author of the report and a past president of the AAS. “We know if we get people through a suicidal crisis, most of them will never end up dying by suicide.” Yet these interventions can only work when they actually reach the people who need them. One obvious way to make that connection is through mental health professionals—such as therapists, psychologists and social workers. About a third of those who commit suicide had come into contact with mental health services in the year before they died—and about a fifth had done so during the past month. Yet there are no national standards requiring these workers to know how to identify patients at serious risk of suicide or what techniques help them survive. If there were, perhaps some of those deaths could have been avoided. Primary care doctors are in an even better position to help but are similarly lacking the tools to do so. They prescribe more than half of all psychotropic drugs, and 77 percent of people who die by suicide had contact with their primary care provider in their last year of life—45 percent in just the past month. Yet most physicians do not learn how to identify those at risk of suicide or what to do to help them. These arguments have fallen on deaf ears at the guilds overseeing these professions, who often argue that their training programs are burdened by too many requirements already. But suicide prevention should be among those requirements. For some patients, it is the most significant and only service that really matters. Things tend to change, however, when state governments take on the issue themselves. In September 2017 California became the most recent state to pass a law requiring suicide prevention training. To get a California license, a psychologist must complete six hours of education in suicide risk assessment and intervention. Nine other states have similar laws, and another four encourage this training but do not require it, according to the American Foundation for Suicide Prevention. Washington State is the only one, however, that extends the education requirement beyond mental health providers to all health workers, including doctors, nurses, and even dentists and naturopaths. More states should follow in
Washington's footsteps. Suicidal thoughts do not have to be
a death sentence. Research has found treatments that work,
and it's time to make sure people receive them. Triggers Identifying Triggers Write “Triggers” on the second tab and insert several sheets of paper. On the first page, write down those things that, if they occur, might cause an increase in your symptoms. They may have triggered or increased symptoms in the past. It may be hard to think of all of your triggers right away. Add triggers to your list when ever you become aware of them. It is not necessary to project catastrophic things that might happen, such as war, natural disaster, or a huge personal loss. If those things were to occur, you would use the actions you describe in the triggers action plan more often and increase the length of time you use them. When listing your triggers, write those that are more possible or sure to occur, or which may already be occurring in your life. Some examples of common triggers are:
Triggers Action Plan On the next page, develop a plan of what you can do, if a trigger come up, to comfort yourself and keep your reactions from becoming more serious symptoms. Include tools that have worked for you in the past, plus ideas you have learned from others, and refer back to your Wellness Toolbox. You may want to include things you must do at these times, and things you could do if you have time or if you think they might be helpful in this situation. Your plan might include:
If you are triggered, and you do these
things and find they are helpful, then, keep them on your
list. If they are only somewhat helpful, you may want to
revise your action plan. If they are not helpful, keep
looking for and trying new ideas until you find the most
helpful. You can learn new tools by attending workshops and
lectures, reading self-help books, and talking to your
health care provider and other people who experience similar
symptoms. How To Encourage
Someone To See A Therapist Here are some steps you can take to tell your loved one about the benefits of seeking therapy. Show Support Misconception about mental health and therapy has intensified stigma in society. Your loved one may be aware that they need help, but may be afraid to seek it if they think you will judge or treat them differently. Therefore, it is essential to use non-stigmatizing language when talking with them about their mental health. Assure them that you will support them through the therapy process. Demi Lovato is one of the most vocal celebrities about her mental health issues. She mentioned on multiple occasions how important it was for her to have people around that really care about her wellbeing. She credits her support group for being able to go through everyday life. Demi asks for advice from her loved ones and asks them to let her know when they feel something’s off: "So whether it's with my management team or with my friends, every choice that I make, I run by people. And that's what's really helped me—vocalizing what you need." Be Sensitive To Timing And Place Talking to someone about mental health requires emotional sensitivity as well as physical sensitivity. The “where” and “how” the topic is presented may determine how a person reacts to your suggestions. Your loved one may not be as bold as Kesha when she shared her condition and struggles with the world while receiving an award. Don’t start this delicate conversation in front of other people or where others can hear as this may cause discomfort. And avoid grouping up in an intervention-style conversation as people do on TV shows. Allow the person struggling to decide whether they want others to know. This way, they feel respected and in control of their own treatment. Also: Avoid talking to someone when they are in a bad mood, tired, have tight deadlines at work or if they’re doing something important. They may dismiss you or disregard the weight of the topic. Approach the person when they’re in a good mood, relaxed and undistracted. Try as much as possible to keep the conversation private, friendly and relaxed. Prepare For Resistance Not all people who hear about therapy will be willing to try it out. You need to be prepared to make your case if your loved one resists your suggestion. Here are some ideas that you can use to highlight the importance of therapy:
Offer To Help You can try to embolden someone to go to therapy, but unless you are willing to offer meaningful support, it’s not going to encourage them. Some people do not know where to start when seeking help. Guide them in finding a suitable therapist in the area, depending on their preferences. You can contact offices on their behalf or research various professionals, their credibility and reviews. Some people are scared of seeing a therapist alone or signing up for group therapy. Offer to go with them until they’re comfortable. You can sit in the waiting room during their first few sessions. Make sure to assure them that you won’t ask prying questions about the counseling unless they want to share. Seeking therapy is one of the best
steps that a person with a mental health condition can take.
However, it’s an effort that requires great strength
and courage. Share your suggestions as openly as possible
and leave them to make the decision that best suits their
needs. Above all things, assure them of your continued love
and support throughout the process. Find instant
support & online therapy Choose your own listener Want to connect with a listener based on life experience or affiliation? Browse or search our listener community to find the right listener or online counselor, someone with whom you feel comfortable chatting. Whether you want listening or online counseling about life, love, relationship problems, stress, depression help, or you just need to vent about your problems, we have an active listener or therapist for you to vent to via anonymous chat. Get online therapy in your anonymous, private room 7 Cups respects your privacy. Our bridging technology connects you one-on-one to a listener or online therapist while remaining completely anonymous. Our friendly Noni bot will welcome you to your private room where you can get settled and learn a bit more about how you can feel better. Your listener will join you in just a few seconds for a confidential chat. Connect & Talk to strangers Learn & grow with the community. Chat with supportive people in group support rooms who have overcome similar challenges. Engage in guided discussions or lighthearted banter. Join conversations about issues and struggles that matter to you in our community forum. Follow positive, kind people you meet at 7 Cups and post about how you are taking care of yourself to your own support network. Stay emotionally fit and grow with us Make emotional wellness a daily habit by following your growth path. Reminders and progress along your path can help you get support from trained volunteer listeners and do simple activities on your own to relax, on a regular basis, giving you more control over your own well being. What is a Growth Path? Do you need help with your life? 7 Cups is an on-demand emotional health and well-being service. When you need to chat we connect you to a real listener or therapist when you want someone to talk to. When you may not feel ready to chat, you can try simple activities to help boost your mood. Whatever step you take first - chatting one-on-one, doing solo activities, watching short videos, reading self-help guides, forum posts, and uplifting feed posts, or participating in group discussions - starts you on a path that will encourage and support you as you take steps daily to become stronger. There are many ways to receive support online -- therapy, counseling, coaching, and guidance are among them. New technologies, like those provided through 7 Cups, allow us to offer affordable, convenient, flexible, accessible counseling to fit your individual needs. What is Online Therapy? Online therapy is mental health counseling provided via the Internet. Sometimes it is called e-therapy, distance therapy, telehealth, or Internet therapy. Online therapy can be done by texting, video chatting, voice messaging or audio messaging with licensed therapists online. What about Video Chat Therapy? While video chat therapy does allow for more accessibility, it does not eliminate some of the key challenges that traditional therapy faces. More and more clients are now opting for message therapy as an even more convenient and affordable solution. Consider how Online, Message-Based Psychotherapy has the ability to improve upon traditional office-based counseling services
Why Clients & Therapists Often Prefer Text-Based Psychotherapy:
Source: www.7cups.com/
People
Who Talk to Themselves Aren’t Crazy, They’re
Actually Geniuses You’re a genius. I mean, this should be a no-brainer, right? After all, some of the smartest people in history talk to themselves: poets, writers, philosophers, every one! Even Einstein used to “repeat his sentences to himself softly.” But now, we have proof. Proof, I say! A study printed in The Quarterly Journal of Experimental Psychology claims that talking to yourself makes your brain work more efficiently. Authors Daniel Swingley and Gary Lupyan hypothesized that talking to yourself could actually be beneficial. Their first trial, in which they gave subjects an object to buy at the grocery store, seemed to prove their point. The people who were allowed to say the name of the item aloud were much more likely to find it than the ones bound to silence. It turns out that talking out loud might not always be helpful, though. “Speaking to yourself isn’t always helping – if you don’t really know what an object looks like, saying its name can have no effect, or actually slow you down. If, on the other hand, you know that bananas are yellow and have a particular shape, by saying banana you’re activating these visual properties in the brain to help you find them.” Basically, if you know what an object looks like – the banana, for instance – then saying the word will help you find what you’re looking for. But, if you’ve never seen a rutabaga, saying it out loud isn’t going to be of any assistance at all. Not that you’d ever actually want to find a rutabaga, but in case you do, here’s a picture. It can be helpful for the indecisive scatterbrains among us. Talking through things aloud can help organize your thoughts, as well as validate difficult decisions, according to psychologist Linda Sapadin “It helps you clarify your thoughts, tend to what’s important, and firm up any decisions you’re contemplating.” I mean, basically, it’s best to talk the big decisions out…even if it’s just with yourself. Talking to yourself about your goals also helps you attain them. It turns out saying your goals aloud is even better for achieving them than making a written list, which can seem daunting. As Sapadin says, “Saying your goals out loud focuses your attention, reinforces the message, controls your runaway emotions, and screens out distractions.” It’s exactly what we
“crazies” who talk to ourselves have always known
– we’re smart, and we give great advice. Why not
listen to it, out loud and wherever you want! Q:
How Do You Find a Therapist? According to WebMD, finding a therapist can entail getting a therapy provider list from an insurance company and asking family or friends if they would trust someone on that list. Finding a therapist can also include contacting a local college or university's psychology or psychiatry department for recommendations. FULL ANSWER The American Psychological Association also recommends consulting a local or state psychological association, a mental health center or a religious center such as a synagogue or church. WebMD notes that people who are currently in therapy, but plan to move, can ask their therapists for referrals to therapists who practice in the new location. Questions can help narrow down the list of potential therapists, according to both WebMD and the APA. Questions include: How long has the therapist been in practice? What is his speciality? What does he charge, and what are his policies? WebMD explains that during and after the first few appointments, people should ask themselves how they feel with the therapist. They should feel somewhat comfortable but not overly so because the purpose of therapy is not general gabbing. The therapist should ask patients what their ideal outcome is and how they see progress measured. For children who need therapy, pediatricians and other parents can offer good referrals. Q: How Do You Find a Good Psychiatrist? A: QUICK ANSWER To find a good psychiatrist, ask for a referral or recommendation from your physician, check to see what specialists are covered under your insurance and ask your friends or family, according to Mayo Clinic. Another good option is to check with local mental health organizations. FULL ANSWER Another recommendation for finding a good psychiatrist is by checking with a local teaching hospital, notes Psych Central. Many teaching hospitals offer low-cost or free psychiatric consultations. Not only can you get more information about the treatment you need, but they can provide you with a list of psychiatrists that can help you the most, including those that cater to the special area of psychiatry you need. Good qualities to look
for in a psychiatrist or other mental health provider are
excellent training and education, proper licensing and
plenty of experience, says Mayo Clinic. The person looking
for a new psychiatrist looks at qualities such as the
treatment approaches and philosophy of the mental health
provider, her office hours and length of sessions, pricing
and if she accepts insurance. Looking at her specialties,
such as anxiety or post-traumatic stress disorder, is also
important. Red flags for psychiatrists include those that
don’t offer a consultation or take a long time
responding to emails or phone calls. Resources for
Providers Screening and Assessment
Clinical Practice Guideline The U.S. Department of Veterans Affairs and the Department of Defense (VA/DoD) established a Clinical Practice Guideline for the assessment and management of patients at risk for suicide. The guideline identifies critical decision points in the management of suicide risk behavior, and provides clear recommendations on incorporating current information into practice. The guideline is only a tool to assist providers, and is not a substitute for clinical judgment. Suicide Prevention, Intervention, and Postvention
Source: www.ihs.gov/suicideprevention/providerresources A
helpful list of mental health resources to remind you
there’s always hope If you or someone in your life is struggling with mental health issues, know you're not alone, and that help, support, and treatment methods are available. SEE ALSO: Don't know how to open up about your mental health? Lady Gaga's mom has some advice. Here's a list of organizations and hotlines that offer support, provide additional informational, and connect you with other impactful professionals and resources. Emergency Medical Services If time-sensitive or potentially life-threatening emergencies arise, consider calling 911 and seeking professional medical care. The National Suicide Prevention Lifeline The National Suicide Prevention Lifeline is a free, confidential service that connects anyone experiencing suicidal thoughts or emotional distress with local crisis centers across the United States. Can't sleep? Call 1-800-273-8255 or text "SOS" to 741741 for help & support. 24/7/366 You can also find an international list of suicide hotlines here. If you're looking for someone to talk with, you can also text Crisis Text Line at 741741. The mobile service offers 24/7 support from trained crisis counselors in the United States at no cost. Your experiences are yours alone, but you never have to be alone in them. Text SOS to 741741 for crisis support in the US, text SOS to 686868 for support in Canada. LGBTQ support The Trevor Project is a nonprofit organization dedicated to helping LGBTQ youth by providing crisis intervention and suicide prevention methods. Trained counselors at the organization can be reached 24/7 through an online chat, by texting "Trevor" to 1-202-304-1200 Monday through Friday from 3pm–10pm EST, or by calling the TrevorLifeline any time at 866-488-7386. The organization also offers TrevorSpace — a safe online space for members of the youth LGBTQ community to interact with one another, build meaningful relationships, and offer support. Trans support Trans Lifeline is another option for transgender people seeking help in time of emotional crisis. Currently, the hotline is staffed by trans volunteers 18 hours a day, every day of the week. United States residents can call (877) 565-8860, and people in Canada can call (877) 330-6366. National Sexual Assault Hotline Survivors of sexual harassment and assault can reach out to the national the Rape, Abuse & Incest National Network’s confidential hotline to speak with a trained member of local RAINN affiliate organization. By calling 800-656-4673 or using the live chat online, you can discuss your experiences, obtain medical and legal information, and receive additional resources and support. As the largest anti-sexual violence organization in the United States, RAINN also offers a comprehensive list of resources to help assault survivors and their loved ones. Veterans Crisis Line The Veterans Crisis Line provides confidential support for veterans and service members, as well as their families and friends. Trained responders from the U.S. Department of Veterans Affairs are available through online chat, by texting 838255, or by calling the toll-free hotline at 1-800-273-8255. A helpful list of mental health resources to remind you there’s always hope Find local mental health centers and professionals The Substance Abuse and Mental Health Services Administration (SAMHSA) helpline provides insight on mental health and substance misuse issues, offers treatment referrals, and shares prevention and recovery methods You can call at 1-800-662-HELP (4357) or find local treatment centers on SAMHSA's website. Mental Health America also provides information on local support groups as well as an interactive tool that will help determine where you should seek help. Explore online resources For more information, guidance, and support on which steps to take if you or someone you know is experiencing mental or emotional distress, here are some great references:
Be aware of suicide warning signs and how to respond to them Not all people experiencing suicidal thoughts show obvious warning signs, but it's important to know what behavior to look for. Signs, according to the Suicide Prevention Resource Center, include:
If you see a person showing any of those signs, or suspect he or she might be having suicidal thoughts, reach out to a hotline or other resource listed here, or seek assistance from a trusted friend, family member, or professional. Make sure the person is in a safe environment free from alcohol, drugs, firearms, or other means that could be used for self-harm, and offer them your support. Remember: Self-care isn't selfish Though it's easy to forget, your mental health and emotional well-being should always be a priority in your life. Whether you take a mental heath day
from work every now and again or decide to avoid social
media for awhile, it's crucial to set aside time to care for
yourself. Here's a
list of doable self-care suggestions
to consider. A totally
doable, not so intimidating self-care survival guide to
2018 Afterwards, I drove to a bookstore and spent $82.47. I went home, applied a face mask and collapsed onto my bed, escaping into the pages of one of my new books for hours. I met my friend for dinner, cherished every single bite of a cheeseburger, rushed back to my pillow, and fell asleep watching re-runs of The Mindy Project. This was my own personal form of self-care. SEE ALSO: Meditation app aims to help veterans tackle anxiety, loneliness For so many, self-care has been the unsung savior of 2017. You've probably heard the term thrown around daily, but learning exactly what it means and why it's so essential will help to better practice it in the new year. Am I doing this thing right? Self-care methods — personalized rituals that allow people to take a step back from this messy world to prioritize their well-being and preserve their mental health — differ for each individual and in each scenario, so there's really no right or wrong. For Hillary Clinton self-care could mean anything from frantic closet cleaning, long walks in the woods, and playing with her dogs, to yoga or sitting down to enjoy a glass of wine. For Michael Phelps, who's conquered the pressures of Olympic competition but has struggled with depression and anxiety over the years, it's working out or heading to the golf course. The only constant is that methods of self-care must benefit and focus on you. "A lot of times people will say 'I spend time with my kids,' which is great and meaningful but that’s still taking care of somebody else," said Monnica Williams, Ph.D., a clinical psychologist and associate professor at University of Connecticut's Department of Psychological Sciences. "When you self-care it’s really about you recharging." Self-care isn't selfish Some people abstain from self-care for fear that their behavior would come across as selfish. They simply can't resist the urge to put other people first. According to a 2017 "Women's Wellness Report" from Everyday Health, which studied 3,000 women from ages 25 to 65 in the U.S., 76 percent of women said they were were more likely to put their own personal needs after someone else's. However, more than half of the participants said that taking time for themselves was the greatest factor in achieving wellness. (Disclosure: Mashable and Everyday Health are owned by the same company, Ziff Davis.) "You can’t be the best you in any other "It’s essential for your mental health and your physical health," Williams said, noting that self-care is anything but selfish. "You can’t be the best you in any other contexts if you’re not taking care of yourself." "I heard someone say that it's like putting on your own oxygen mask in an airplane emergency before putting one on a child," added Crystal Park, another professor at the University of Connecticut's Department of Psychological Sciences. "The healthier and more resilient we are, the more effective we can be in our lives." Heading into 2018 with some solid self-care guidelines will help you better manage your stress and survive whatever challenges are in store, so here are a few to keep in mind. Don't be afraid to take a mental health day Your mental health is important, but it's also extremely easy to ignore. When your job gets too overwhelming or events in your personal life prevent or distract you from doing your best work in the office it's time to take a step back. For inspiration, look no further than one of 2017's viral personal tales: the story of Olark CEO Ben Congleton advocating for his employee after learning she'd taken time off for mental health reasons. After Congleton's understanding email sparked discussion about mental health in the workplace, he wrote a post on Medium further emphasizing the need to normalize it. When you are at work, take additional steps to make your environment a place of comfort. Personalize your desk with a plant, a framed photo of something that makes you smile, or set the mood with a tiny lamp. And every so often, book a conference room for lunch with your coworkers to share pizza and a cake you buy for the sole reason of craving cake. Work will still be there when your lunch break ends, but taking time to clear your head is crucial. Give social media and screens a rest Social media usage often starts with the intention of getting caught up on current events and quickly spirals into a black hole of negativity. "So many people are plugged in and instantly alerted to everything that is happening in the news in ways that weren’t possible 10 years ago," said Dr. Carolyn Mazure, director of Women’s Health Research at Yale. While platforms like Facebook, Instagram, and Twitter have been proven to take a toll on self-esteem and mental health, social media isn't all bad. Here are a few ways to make online communities safer spaces for you:
While it's healthy to disconnect from technology every so often, when you do have your phone by your side these tips can help make the experience more enjoyable.
Treat yourself, but treat others, too No matter how small, make a daily attempt to treat yourself to an experience or a purchase that'll brighten your mood. Get a pedicure or massage, take a hot bath, go for a walk around the block, go out with friends, or cancel plans to stay in on a Friday night to recharge and binge-watch mindless television, if that's what you need. And while being good to oneself is key, Park noted "balance is important" in self-care, and making an effort to give back to others often helps people feel better. Consider volunteering, or clean out your closets and drawers to donate unwanted items to charity. Put positivity on display One form of self-care can be as simple as not being so hard on yourself all the time. It sounds simple, but it can be a serious challenge at times. Visual reminders can help. When in doubt, turn to this handy self-care printable, titled "Everything is Awful and I'm Not Okay." The checklist presents 16 questions for you to answer and serves as a helpful reminder to stay hydrated, shower, participate in physical activity, and be kind to yourself. Keep a copy of the printout in your bag for comfort or hang it somewhere you know you'll see it. (Mashable HQ has one on the wall of the women's restroom.) Affirmations are another great way to be kind to yourself and can serve as help. Glancing at inspirational quotes, uplifting doodles, or a few words of positivity can lift your spirits. The Mashable women's restroom also has a few on display. (Very good restroom.) Don't be afraid to ask for help Though the term self-care sounds like an isolated practice, it doesn't have to be. If you're someone who struggles to commit to individual self-care routines, or simply takes enjoyment from the company of others, spending time with and opening up to a friend, loved one, therapist, or even reaching out to the 741741 Crisis Text Line could be extremely beneficial. Just know that you're not alone in your stress and professionals are out there to help. "Certainly, if possible, try to see a stressful situation as an opportunity to grow, and consider the power of reorienting how you confront a stressful situation when it arrives," Mazure said. "Instead of thinking, 'Oh no, not again,' perhaps a good self-care perspective might be, 'I’ve seen stress before. I've got this.'" If you want to talk to someone or are
experiencing suicidal thoughts, text SOS to the Crisis Text
Line at 741741 or call the National Suicide Prevention
Lifeline at 1-800-273-8255. Here is a list
of
international resources. We
tell suicidal people to go to therapy. So why are therapists
rarely trained in suicide? "See a therapist." And yet suicide prevention experts say outside of psychiatrists, the majority of mental health professionals have minimal to no formal training in how to effectively treat suicidal people. Suicide-specific training is not commonly offered as part of college curriculums, optional postgraduate training opportunities are limited, costly and time-consuming, and experts say some therapists may not be aware they even need the education. "Any profession’s ethical standards require that you not treat a problem you don’t know, and yet every day thousands of untrained service providers see thousands of suicidal patients and perform uninformed interventions," said Paul Quinnett, a clinical psychologist and founder of the QPR Institute, an organization that educates people on how to prevent suicide. "People think if you send someone, a loved one, to a therapist, that therapist will be skilled in how to address ... their risk for suicide. Nothing could be farther from the truth." Numbers released in January from the U.S. Centers for Disease Control and Prevention show 48,344 people died by suicide in 2018, a small increase from the year before, though the rise in deaths over time has been steady. Since 1999, the suicide rate has climbed 35%. Suicide is the nation's 10th-leading cause of death, yet experts say training for mental health practitioners who treat suicidal patients – psychologists, social workers, marriage and family therapists, among others – is dangerously inadequate. Many suicide prevention experts say combating suicide requires a holistic approach that includes communities, families, educators and religious leaders working together. But society, they say, has placed the burden of caring for suicidal people on a mental health workforce woefully underprepared to help them. In Depth: Funding for suicide lags behind other top killers (Editor: This is very misleading. In Orego, Suicide is the lading causde of death for 15-54 year olds. You see, what U.S.A Today is quoting is from the top 10 leading acuses of death which lump all cancers together. When the CDC separates the cancers and heart diseases to the individual disease, suicide jumps up the ladder. See how your state fairs. (https://bit.ly/2Ry1fqO) There are no national standards that require mental health professionals to be trained in how to treat suicidal people, either during their education or their career. Only nine states mandate training in suicide assessment, treatment and management for health professionals, according to the American Foundation for Suicide Prevention. "Having someone on your side that gets what you're going through, that can advocate for your needs, and that gives you the space to talk through your thoughts is a game-changer." Whitcomb Terpening, a licensed clinical social worker who works exclusively on suicide The American Psychological Association and the Council on Social Work Education, which accredit graduate programs in psychology and social work, have standards to prepare graduates to treat patients in crisis but do not require specific competencies regarding suicide. For its 2014 report on guidelines to improve training among the clinical workforce, the National Action Alliance for Suicide Prevention assessed the state of education by sending surveys to 443 academic institutions. Of those, 69 responded, and 70% said no specific training for suicide was provided. "As I started pursuing my clinical training and I knew I wanted to work on suicide, I got all these head turns," Whitcomb Terpening said. "People said it's not possible to have an out-patient practice where you aren't getting sued, where people aren't dying, where you're not just in crisis situations all the time." A 2012 paper by the American Association of Suicidology cites decades of studies that underscore the training gap, and experts say not much has changed in the last several years. It found about half of psychology students receive formal classroom training on suicide during their graduate education. Only about 25% of social workers receive any suicide prevention training. Marriage and family therapists had even less. Most psychiatrists receive some instruction, but many experts agree it's insufficient. "When people ask me, 'Who should I see?' the only thing I can say is 'See a psychiatrist if you can,' because ... they're supposed to cover that topic during the course of their training," Quinnett said. "You have some assurance that they know something about it. But you can't say that for any other (mental health) profession, which is astounding to me." Suicidal people have a spectrum of experiences with therapy, some harmful, some lifesaving. Many people living with suicidal thoughts say when they found the right clinician, someone who didn't overreact and who made an earnest effort to understand their pain, they felt less suicidal. "Having someone on your side that gets what you're going through, that can advocate for your needs, and that gives you the space to talk through your thoughts is a game-changer," said Whitcomb Terpening, a licensed clinical social worker and founder of The Semicolon Group, a therapy practice in Houston that works exclusively on suicide. "They'll have your best interest in mind, not just to keep you alive, but to help you find a life worth living." Facing suicide, patients are afraid, and therapists are lost When someone who's feeling suicidal opens up to a therapist, they do so expecting the person sitting across from them wants to understand their suffering. But Stacey Freedenthal, a suicide attempt survivor and associate professor at the University of Denver Graduate School of Social Work, says a common feeling among therapists when they realize they're sitting across from a suicidal person is panic. They worry the patient might try to kill themselves, could succeed and they may get sued or lose their license. Their reflex is to send the patient to an emergency room. "You’ve got this person who has taken weeks or months or more to work up the nerve to go to a professional and the professional is saying, 'I can’t help you, you have to go somewhere else.' And that can be very harmful," Freedenthal said. Research shows emergency room visits and involuntary hospitalizations – triggered when a mental health professional believes someone is at imminent risk of killing themselves – can increase a person's risk of suicide. Susan Stefan, a scholar and litigator on behalf of people with psychiatric disabilities, says that in many cases, an emergency room can be the worst place for a suicidal person. In many cases, an emergency room can be the worst place for a suicidal person, says Susan Stefan, a scholar and litigator on behalf of people with psychiatric disabilities. "It's loud, it's hurried, people are in a rush," she said. "There is no training, generally, for emergency physicians, or staff to deal with suicidal people. In many places, there's not much sympathy." Even if a therapist doesn't overreact, that doesn't mean they know how to help. Freedenthal says she once had a therapist who made her "promise" she would never do anything to hurt herself. "That’s great in principle, but I kind of wouldn’t have been going for help if it was that easy," she said. "I think we as a society waste a lot of time trying to stop people from killing themselves as opposed to exploring why they want to die in the first place." Susan Stefan Some therapists try to avoid the question of suicide altogether. Freedenthal says she always asks her students and even colleagues with decades of experience, "What is your fear about asking someone if they're thinking of suicide?" The most common answer: "That they'll say yes." Some chronically suicidal people say they've been dropped by therapists who were unable to tolerate the intensity of their pain. Others say their clinicians were so fixated on predicting how likely they were to kill themselves, they didn't spend enough time listening to why they were hurt or what they might need. "A lot of people who say they're suicidal are trying to convey the depth of their despair," Stefan said. "I think we as a society waste a lot of time trying to stop people from killing themselves as opposed to exploring why they want to die in the first place." ‘They didn’t even know how to ask the question’ Back in the 90s, Quinnett was the clinical director at a mental health center in Spokane, Washington. One year, they lost 13 patients to suicide. When Quinnett reviewed the death records, he realized his clinicians didn't know how to treat suicidal patients. "They were good people. They were goodhearted. They were crushed when their patients died, but they didn't even know how to ask the question, let alone how to assess and manage the risk," he said. Afterward, Quinnett said he helped put together a comprehensive, mandatory training program on suicide. Once it was fully up and running, he said clinic deaths plummeted, to one or none a year. Eventually a new CEO took over and Quinnett said he decided to shutter the program over cost concerns. Quinnett said suicides started up again, so he quit. About 10.6 million people seriously thought about suicide. Almost all mental health professionals see suicidal patients at some point in their careers, experts say, yet only a small fraction seek out specialized training. For those who do want it, it can be hard to come by. Some of the best therapies aren't available for training at scale, and those that are require time and money. David Jobes is director of the Catholic University of America's Suicide Prevention Lab and created CAMS – Collaborative Assessment and Management of Suicidality – widely regarded as one of the most effective approaches to treating suicidal patients. In the absence of training, Jobes said many clinicians spend most of their time trying to treat a patient's underlying mental illness, rather than asking the person, "What makes you want to kill yourself?" CDC data published in 2018 shows 54% of people who died by suicide had no known mental health condition. CAMS, Jobes said, is a model that endeavors to understand the sources of people's suffering. But very few people are trained, he said, and those who could benefit from it most have probably never heard of it. Andrew Evans, president of CAMS-care, which trains practitioners on the CAMS approach, said last year that the company trained about 5,000 mental health professionals in the U.S. "Unless you seek out on your own specialized training, and most people do not get this, it will become exquisitely painful for you and impact your well-being." April Foreman, a clinician and board member of the American Association of Suicidology "That's a drop in the bucket, because millions of people have suicidal thoughts," said Jobes, noting CDC data from 2017 that showed 10.6 million American adults seriously thought about suicide. Terpening, who works with suicidal patients, says that as long as training for mental health providers is voluntary, patients won't get the care they need. "Everyone's told 'Reach out, there's always somebody to talk to.' But there isn't. Because we're not trained in graduate schools, we're not trained in our clinical intern hours, we're not offered those kinds of opportunities," she said. Lack of training, Terpening added, doesn't just leave practitioners ill-equipped, it leaves them afraid. "Therapists want to do well, they just don’t know how," she said. "Fear is born out of the unknown." Many therapists are so frightened of treating suicidal people they'll screen out potential patients who they think may be at risk, Quinnett said. Clinicians also are afraid of liability, though Stefan said the concern is far less real than most mental health professionals think. Even if a grieving family sues, she said, most cases are not successful. Facts, however, are not always persuasive when the undesired outcome feels so catastrophic. A survey of mental health providers in Colorado, which has one of the highest suicide rates in the nation, showed many do not think they need more training, but desire it, according to a 2018 article in the Journal of Public Health Policy. It found providers reported being "generally pleased with their existing training and felt prepared to address suicide within their practice," though 80% supported mandating suicide-related continuing education. Training helps therapists care for their patients and for themselves When confronted with the intensity of pain a suicidal person is feeling, some therapists find themselves overwhelmed – wanting to help, fearing they're not capable, with stakes that feel enormously high. "It is emotionally painful," said April Foreman, a clinician and board member of the American Association of Suicidology. "Remember, you’re a therapist because you’re emotionally sensitive, and then we give you training to be even more sensitive. Then we put you in a room with someone who has the kind of pain and despair and behaviors that put them at risk of dying. "Addressing suicide risk is not something you can get trained in once and be done. This is such a hard problem with such serious consequences that people are going to feel and be unprepared unless they are engaged in an ongoing way." Anthony Pisani, associate professor of psychiatry and pediatrics "Unless you seek out on your own specialized training, and most people do not get this, it will become exquisitely painful for you and impact your well-being." Foreman says therapists practicing Dialectical Behavior Therapy, another highly effective treatment approach for severe suicide risk, are expected to have a consultation team to help manage stress and burnout. "I will tell you, having lost patients to suicide, the consultation group is invaluable," she said. Terpening says being able to talk with peers is a crucial part of her own self-care. "The work can be isolating," she said, "so to be able to hear from other people is so helpful and so healing in ways that a spin class never could be." Calls to fix broken system go unheeded The issue of inadequate training has been documented for decades. In 2001, the National Strategy for Suicide Prevention said it was critical that "mental health personnel receive appropriate graduate school training on the subject of suicide while preparing for their professions." Nearly 20 years later, experts say not enough has changed. Anthony Pisani, associate professor of psychiatry and pediatrics at the Center for the Study and Prevention of Suicide at the University of Rochester, said it is essential the goal be met, and training must extend well beyond school. "Addressing suicide risk is not something you can get trained in once and be done," he said. "This is such a hard problem with such serious consequences that people are going to feel and be unprepared unless they are engaged in an ongoing way." The American Association of Suicidology report on gaps in mental health training made several recommendations for improving care. It said accrediting organizations must include suicide-specific education as part of their requirements so graduate programs have the training in their curriculum. State licensing boards, it said, must require clinicians be competent in suicide treatment. And the report said government has a role to play, too, by requiring that health care systems receiving state or federal funds ensure their mental health professionals are trained in suicide risk detection, assessment, treatment and prevention. Maybe, most importantly, experts say clinicians have to overcome their fear of not knowing with certainty who may live or die. "I get the fear – our licenses are our livelihood, we need to be able to protect them," Terpening said. "But we also have to be able to see past the risk to do what's right for our patients." If you or someone you know may be struggling with suicidal thoughts, you can call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255) any time day or night, or chat online. Crisis Text Line also provides free, 24/7, confidential support via text message to people in crisis when they text SOS to 741741. The American Foundation for Suicide
Prevention has resources
to help if you need to
find support for yourself or a loved one. Supporting
Teenagers and Young Adults During the Coronavirus Crisis Here are some tips for parenting teenagers (and young adults suddenly home from college) during this time. Emphasize social distancing The first challenge with teens and young adults may be getting them to comply with the guidelines for social distancing. Teenagers tend to feel invincible, points out David Anderson, PhD, a clinical psychologist at the Child Mind Institute, and they may think that the new coronavirus is not as problematic for their age range as it is for older people. Parents are reporting a lot of pushback when teens are told they can’t go out and get together with friends. “They want to see their friends, and don’t see why the social distancing should apply to them,” says Dr. Anderson. Parents are asking what to tell them. “Our answer is that exposure to this virus is an exponential thing, and that it’s not really about them,” says Dr. Anderson. “It’s not really about the fact that they feel fine. It’s the fact that they could be asymptomatic carriers and they could kill others, including their grandparents.” One thing to emphasize, he adds, is: “You just can’t know that your friends are well. And while you may be comfortable taking that risk, you’re also bringing that back in your house.” It’s also important to help your teenagers understand that no one really knows yet how the coronavirus affects people of different age groups — contracting the virus might be very dangerous for your teenager, even though the facts are still unclear. Understand their frustration over not seeing friends For teenagers and young adults, friends are hugely important, and they are supposed to be — bonding with peers is one of the essential developmental tasks of adolescents. If your teen is sulking about being stuck at home with parents and siblings, a direct conversation might be helpful, says Rachel Busman, PsD, a clinical psychologist at the Child Mind Institute. Acknowledge that you know it’s frustrating for them to be cut off from friends. Listen to what they’re feeling, validate those feelings and then be direct about how you can work together to make this situation bearable. Loosening rules about time spent on social media, for instance, will help compensate for the socializing time lost with school closings. Encourage them to be creative about new ways to interact with their friends socially. Support remote schooling Parents are reporting feeling pressured and confused about how to help kids with remote learning. With younger children, notes Dr. Anderson, it’s more a matter of finding fun activities that can be educational. But with older students, keeping up with expectations from school can be challenging, especially for those with ADHD, learning disorders or organization issues. “I’m completely overwhelmed by trying to figure out how to structure a school day,” one mom told us. “I was never planning on homeschooling my kids. I don’t have training in this.” You can help teenagers — and college students who’ve been sent home — create a realistic schedule for getting work done in defined periods, building in breaks and times for socializing, exercising and entertainment. The key principle: do a session of work first, then reward yourself with something relaxing. Keep in mind that it’s not going to be as effective as school, but it may get to be more effective over time as everyone on the school front, as well as the home front, works to improve remote learning. Encourage healthy habits Teenagers and young adults will do better during this stressful time if they get adequate sleep, eat healthy meals and exercise regularly. Keeping a consistent sleep schedule, with predictable times to wake up and go to bed, is especially important to maintaining a positive mood and their ability to fulfill academic expectations. Healthy habits are particularly important for young people who may be struggling with anxiety or depression. Losing the routines you’ve come to rely on can be a big source of stress, so Jill Emanuele, PhD, a clinical psychologist at the Child Mind Institute, recommends establishing new routines. “Make sure you’re eating properly and sleeping and being social and engaging in pleasant activities, ” she says, while also warning that young adults should avoid sleeping too much when they’re housebound. “There’s more of an ability to sleep at home, and while rest is important right now you still need to be active.” Dr. Emanuele also notes that having family members around more often can feel overwhelming or create strain. “Families will need to diffuse tensions in the home with parents and siblings, because everyone is going to be stressed out more,” she says. “How to do it will be different for every family, but parents are going to want to think about when to give young people more freedom and how to make sure that their kids’ time is still structured. Everyone should be contributing in some way.” Validate their disappointment For many the most painful part of the coronavirus crisis will be losing important experiences: high school sports seasons, proms, theater productions, high school and college graduations. And while we’re all missing out on very valued activities, adds Dr. Anderson, “it’s especially problematic for teenagers who are wired in their brains to think about novelty and pleasure seeking and seeking out new frontiers to be limited in this way.” Give them room to share their feelings and listen without judgment (or without reassuring them that everything will be fine). Some will be worried about missing activities expected to help them with college applications and scholarships. Kids are understandably wondering how this will affect their futures. Again, give them room to share how they are feeling and acknowledge the real stress they may be under. Then express confidence in your child’s ability to rebound. Help them practice mindfulness Mindfulness techniques can be very helpful in this kind of situation, where our routines are disrupted and we may feel overwhelmed by frustration and disappointment. Mindfulness teaches us to tune into our emotions in any given moment and experience them without judgment. In what’s called “radical acceptance,” we let ourselves sit with our emotions rather than fighting them. As Joanna Stern, PsyD, a clinical psychologist at the Child Mind Institute, explains, “You tell yourself it’s okay to feel anxious right now. It’s okay to feel scared. It’s okay to feel angry. You’re accepting the feelings you have and validating them because we’re all having those feelings. It’s really important that you accept them as they are rather than fighting them.” In other words, says Dr. Stern,
“We say to ourselves: ‘This sucks, and I’m
going to be sad about it, and I’m going to be angry
about it, and I’m going to feel anxious about it,’
or whatever it is. This then allows us to move on and say,
‘Okay, so now what needs to be done?’” Texting,
Messaging & Chat Compared In this blog post we compare three options: Texting (SMS), Mobile Messaging and Online Chat. While these terms often get used interchangeably, they are in fact three very different options, each with their own characteristics to consider. We leave out voice calls because they've fallen down the pecking order of preferred smartphone apps. We're also leaving out app notfications and email because neither are effective at supporting full conversations on mobile devices. Text, Messaging, and Chat compared Online Chat “Online chat may refer to any kind of communication over the Internet that offers a real-time transmission of text messages from sender to receiver. The first dedicated online chat service that was widely available to the public was the CompuServe CB Simulator in 1980.” (Wikipedia). Chat is also a verb that can be applied to any texting activity but here we are talking about a solution category. Online or web chat is very different from Texting and Messaging. Chat is used frequently used by customer service when a customer is online and needs help. It has been designed to solve problems in the online environment and falls short when moved to a mobile environment. Chat is also not used for building and maintaining engagement through an extended conversation. Example chat vendors are listed in this Mobile Engagement Vendor Landscape blog post. Texting (SMS) Short Message Service (SMS) is also called text messaging or texting. It was invented 30 years ago as a way to send text-based messages through the cellular network. SMS comes preinstalled on your mobile phone. I mostly use the Samsung SMS app to communicate with my friends and with businesses (old school). Texting is very popular and widely used globally. SMS supports 160 characters of data before it wraps to a new text message. Multimedia Messaging Service (MMS) is an extension of SMS and supports pictures, audio, and video. SMS sends messaging over the wireless network's control channel, which is a separate data-only channel used to control the "bearer" channels that carry voice conversations or cellular data. This means you need to have wireless network coverage for SMS to work. SMS Texting and Messaging Compared Messaging Apps Modern messaging applications first started to appear in 2005 in the form of apps like Facebook Messenger, WhatsApp and similar services. Messaging is immensely popular, with the combined user base of the top four messaging apps (WhatsApp, Messenger, WeChat, Line) being larger than the combined user base of the top four social networks (Facebook, Youtube, Twitter, Linkedin). Additionally, more messages run through messaging apps than over SMS. Messaging is how people communicate and has become the fabric of daily life. And as such, needs to be understood by the enterprise when determining how they will communicate and have a conversation with the digital consumer. “Asynchronous messages, conversations, and the conversation list form the basis of mobile messaging. It is the combination of all of these behaviors and expectations in messaging that make it such a dominant part of people’s digital lives. It is what makes messaging the most comfortable communication medium ever invented…. The comfort of messaging has had real consequences in making it the most engaging and popular activity on our most personal devices.” (Ben Eidelson) Messaging was once a simple service for exchanging messages, pictures, videos, and GIFs but is has evolved into ecosystems with their own developers, apps, and APIs. Now messaging apps can be built into a mobile solution to become part of the in-app (or mobile web or other UI) experience. There are two important categories of Messaging apps: consumer personal use and enterprise use. Personal use apps are the ones here like Facebook Messenger. Enterprise-grade messaging apps like our My:Time messaging solution follow the same communication framework but provide robust and scalable features needed to run a large scale business. My:Time™ also packages this framework to be an end-to-end messaging solution for the enterprise with all the components and services needed to support next generation customer service strategies. Comparison: Texting vs Messaging vs Chat The table below provides additional comparison of the three communication options. Messaging is a very compelling option that needs to be considered for all engagement strategies, including those where you would typically deploy online chat. In some niches, Texting (SMS) works really well (see use cases below) and might be a better option. Our comparison shows major differences
between texting, messaging and chat. Each option has
enterprise use case where it best fits. If you need more
help sorting out the options, shoot us an email or give us a
call. Can
AI therapy help ease America’s mental health
crisis? 12/20/23 A small handful go even further by offering actual therapy, not from a human, but powered by artificial intelligence. Apps like Woebot and Wysa include AI-powered chatbots that can maintain a complex text-based conversation with users and respond to their inputs using many of the same treatment strategies that real therapists rely on — including an often passable re-creation of human empathy. There have also been reports of people turning to popular AI chatbots like ChatGPT, which were not designed to serve as digital therapists, for mental health support. It’s estimated that 1 in 5 American adults lives with depression, anxiety or some other mental illness. Therapy has proven to be very effective in helping people manage these conditions. But a long list of barriers — including a nationwide shortage of therapists, spotty insurance coverage and lack of access — mean that more than half of those with a mental illness don’t receive treatment. AI therapists, at least in theory, could help fill this massive gap in mental health care. Why there’s debate Even the most enthusiastic backers of AI therapy say the technology is not at a point where it’s ready to replace human therapists, at least not yet. They do believe, though, that it has become sophisticated enough to be an important supplement to regular mental health care, especially for those whose conditions will go untreated if the only option is a real-life practitioner. Some research suggests that people can develop strong connections with AI therapists and that the programs can have a positive impact — particularly when providing the more systematic forms of psychological treatment like cognitive behavioral therapy. Skeptics say there are too many risks to trust AI to provide therapy to emotionally vulnerable people. There are already examples of the systems providing dangerously incorrect advice or being used unethically. Others have major concerns about privacy, oversight and accountability when something goes wrong. On a deeper level, though, many experts believe that the human-to-human connection is the foundation of effective therapy and, that no matter how well AI might mimic that bond, it will never actually replicate it. What’s next None of the available AI therapy
options have been approved by the Food and Drug
Administration, meaning they’re unregulated and
aren’t legally considered to be an alternative to
traditional therapy. That could soon change. Wysa’s
chatbot is currently being put through an expedited research
phase that could lead to it being approved by the FDA as
early as next year. Teen
Therapy and Psychiatry Online: Hit or Miss? Medpage -
3/3/24 I recently assessed a teenager hospitalized for an acetaminophen (Tylenol) overdose. Prior to the incident, she had sought online mental health therapy but discontinued it due to a lack of rapport and privacy concerns with telehealth. Her condition escalated to the overdose, which came to light only after she confided in a friend, who then alerted the school counselor. Her parents struggled to secure in-person therapy post-COVID, as she rejected online treatment. In the wake of a pandemic that has amplified the mental health crisis among teens, the shift toward online therapy, exemplified by New York City's recent $26 millioinvestment or window in Talkspace, raises concerns. While telehealth has expanded access, it sometimes falls short in addressing the complex emotional and psychological needs of our youth, particularly in severe cases, like that of my patient. This patient's incident also underscores the critical role of friends and school-based support systems: in-person care, especially within schools, is essential for effectively addressing the youth mental health crisis. The Worsening Youth Mental Health Crisis I penned an op-edopens in a new tab or window on the pediatric mental health crisis 2 years ago, which coincided with a Surgeon General's advisory or window and emergency declarations or window from leading medical organizations. Teen mental health issues had been on the rise for a decade preceding COVID and reached crisis levels during the pandemic. The CDC disclosed alarming statistics or window: a third of high school students reported mental health issues, over 25% of LGBTQ+ students attempted suicide, and suicide attempts among female students surged by 50%. By fall 2022opens in a new tab or window, mental health-related emergency department (ED) visits for suicidal-related behaviors among adolescent females were still at or higher than pre-pandemic levels. Yet, even now, far too many severely depressed youths are not connected with consistent treatment. The answer isn't merely increasing ED or inpatient capacity, as children often face long waits or window and have high readmission rates after short stays or window. In fact, the leading pediatric organization avocateds for keeping kids out of hospitals by enhancing community-based mental health services. The CDC recently released a report which, unsurprisingly, found that 5- to 17-year-olds were evaluated more in psychiatric EDs in the spring and fall. School is clearly a significant trigger: transitions into school, academic pressure, bullying, and victimization are likely all at play. The mental health crisis encompasses numerous issues, with the alarming increase in suicidal tendencies among teenagers being particularly critical. This crisis disproportionately affects certain high-risk groups and minorities, including girls and Hispanic, African American, and LGBTQ+ youth. Jewish, Asian, and Muslim children are among those who also experience the challenges associated with minority status. However, recent data show that only 56% of public schools are prepared to meet their students' mental health needs, with 69% observing a rise in demand for such services post-pandemic. Despite this, 88% of schools doubt their ability to adequately serve all students requiring help, hindered by professional shortages, limited external resources, and insufficient funding. Also, only 65% of schools employ full-time nurses; there is just one school psychologist for every 1,127 students, on average, nationally; and in New York City, there is one guidance counselor for every 272 students. Integrating Mental Health Services Into Schools One possible solution is to enhance and expand in-person, school-based mental health servicesopens in a new tab or window to directly address the challenges of online therapy. This strategy utilizes the existing school infrastructure and relationships to offer accessible, timely, and effective support, promoting community and belonging essential for student well-being. Schools naturally provide a supportive infrastructure for children and families, with an increasing number incorporating mental health services directly on-site. For example, our medical center at Columbia has been offering mental health services in 14 local schools since the 1980s, using familiar settings to navigate common barriers such as stigma, missed appointments, and cost. The close relationships school staff have with students and families enable a deep understanding of individual needs, while peer support within this network further strengthens the care provided. Utilizing local resources in this manner makes schools an ideal starting point for effective mental health interventions. Critically, this approach does not negate the value of telehealth but rather positions it as a complementary or "hybrid" tool within a broader, more diversified strategy. The Shortcomings of Telehealth-Only Care Opponents of prioritizing investment in school-based therapy may argue for the efficiency and accessibility of telehealth, especially in reaching remote or underserved populations. In areas where there are few child psychiatrists, online treatment may be better than no treatment. However, this further supports the argument for investing in local school-based care, for both rural and urban areas. While telehealth has its merits, particularly in temporarily bridging geographical gaps, it may fall short in delivering the depth of care required for severe cases. The impersonal nature of online interactions can hinder the formation of a therapeutic alliance, which is foundational in effective mental health treatment. An interesting new study found that talking face-to-face lights up our brains more than chatting on Zoom, suggesting real-life conversations are better for our social brains. The lack of immediate, on-the-ground support systems in online therapy can leave high-risk adolescents without essential safety nets. Mental health providers using apps might not be integrated into the local infrastructure critical to a teen's life. Collaboration between therapists and physicians treating these high-risk patients -- known as "split treatment" -- is vital, yet challenging, even when both professionals are acquainted. This collaboration becomes even more unlikely with a therapist accessed via an app. Furthermore, a 30-minute once-a-month visit, as offered in New York's agreement with Talkspace, complemented by the option to text between visits, may not suffice for the needs of high-risk teens frequently seen in EDs. It's Time for a Change The Mohonasen Central School District in Rotterdam, New York, acclaimed for its mental health program aiding over 400 students in 6 years, recently caught the attention of New York Gov. Kathy Hochul (D). In response, Hochul and the New York State Office of Mental Health just announced they are launching a statewide initiative, dedicating $20 million to establish school-based mental health clinics. This is exactly what we need. The mental health crisis among
adolescents necessitates a strategic shift toward an
investment in enhanced in-person, school-based mental health
services. This approach not only addresses the limitations
of telehealth, but also capitalizes on the unique advantages
of integrating mental health support within the educational
system. By fostering direct, meaningful connections and
building robust support networks, we can offer a more
compassionate, effective response to the mental health needs
of our youth. Ultimately, investing in such an approach is
not just a matter of policy but a commitment to the
well-being and future of our younger generation. Your
robot therapist is not your therapist: understanding the
role of AI-powered mental health chatbots 1. Introduction The World Health Organization (WHO) reported a shortage of investment in mental health services in 2021 (1). This has been one of the many grievous repercussions of the COVID-19 pandemic rippling into a growing need for more mental health care services, overburdening clinicians. Along with the stigmatization of seeking mental health services, there are also barriers to accessing professionals for those who live in rural, remote, or low-income areas (2–7). However, with the rising use of artificial intelligence (AI) in various fields including healthcare, there is great potential for AI to alleviate this scarcity of mental health services (2). One notable method of utilizing AI in psychology is in the form of chatbots which can be used to supplement the work of clinicians (8). These technologies use natural language processing (NLP) and machine learning (ML) processes to simulate human conversation, allowing individuals to easily interact with them to receive support and guidance for their mental health needs (9). By using psychological AI chatbots, individuals can access mental healthcare services from the convenience of their own homes through their mobile phones (4), without the need to schedule an appointment or travel to a clinic. This can be particularly beneficial in contexts where mental health services are lacking, for individuals who live in remote areas, or for those who have difficulty accessing traditional mental healthcare services due to financial or logistical reasons (7). Additionally, psychological AI chatbots can provide support and guidance on a 24/7 basis, allowing individuals to access help whenever and at the frequency they need it (10). Overall, the use of psychological AI chatbots have the potential to greatly improve access to mental healthcare services, making them more widely available and easier to access for individuals around the world (3). One of the key benefits of using psychological AI chatbots for mental healthcare is that they can provide personalized support and guidance. By using ML algorithms, these technologies can learn about an individual's unique needs and preferences, and tailor their responses accordingly. This can help ensure that individuals receive support and guidance that is customized to their specific needs, making it more effective and relevant (6). Additionally, such chatbots can provide a sense of anonymity and confidentiality, which can foster trust among individuals who may be hesitant to seek in-person help for their mental health concerns (4). Furthermore, these chatbots can help reduce the stigma surrounding mental health and make it easier for individuals who experience anxiety when visiting therapists (7–9). By providing a convenient and accessible way to receive support and guidance, these technologies can encourage more individuals to seek help for their mental health needs, thus breaking down barriers to accessing mental healthcare services. Although psychological AI chatbots have the ability to make significant strides in improving and providing mental healthcare solutions, they do not come without their own ethical challenges. One major concern for these technologies is their potential to provide inadequate or noxious support and guidance. Since these chatbots are not human, they may not be able to fully understand nonverbal cues or respond empathetically to an individual in emotional distress (11, 12), resulting in inappropriate responses. Additionally, bias in the data used to train the chatbot could lead to algorithmic bias (7, 9, 12) resulting in individuals receiving inaccurate or even harmful advice, worsening their mental health conditions and further exacerbating discrimination against marginalized and ethnic minority groups (7, 9, 12, 13). In such instances, these technologies could exploit such groups who may be enticed to utilize them as alternative forms of therapy, due to their limited access to mental health services or other social determinants of health, without fully comprehending their limitations (2, 14, 15). The notion that such chatbots can replace a human therapist is a façade that can affect the motivation to seek social support and treatment, creating an over reliance on these technologies (12). Therapeutic treatment often incorporates shared decision-making, trust, flexibility, and interpersonal relations with a therapist. Through an exchange of dialogue, patients are able to advocate for themselves and are able to exercise their individual autonomy (12). However, such engagements are often difficult to build with chatbots as these tools have limited therapeutic capacity and lack the ability to create a space for shared decision-making, thus diminishing one's autonomy. This becomes even more problematic when vulnerable populations; i.e., those who are susceptible to exploitation, limited resources, harms or risks (both physically and emotionally) (16), and with diminished autonomy; utilize these chatbots as their only means to accessing care and treatment (12). Furthermore, due to these concerns, it is imperative that users are aware of the limited therapeutic relationship they can enjoy when interacting with a mental health chatbot. Such chatbots are not intended to replace the role of therapists but rather increase the self-management capabilities of patients' mental well-being (2, 4, 8, 11). Ignorance of or misunderstanding such limitations could lead to a therapeutic misconception (TM) where an individual would underestimate the restrictions of such technologies and overestimate their ability to provide therapeutic support and guidance. This paper will explore and discuss the four ways that TM may occur for users: through inaccurate marketing of such chatbots, forming a digital therapeutic alliance with these chatbots, inadequate design of the chatbots leading to biases, and potentially limiting one's autonomy. Key insights will also be provided on how to mitigate TM to promote the responsible, safe, and trustworthy use of psychological AI chatbots. A hypothetical clinical case study will first be presented of a psychological AI chatbot that allows for a hybrid mode of therapy, through which the issue of TM will be explored and explained. The four ways that TM can be encountered when using AI chatbots in mental health services will then be discussed, followed by a discussion and concluding remarks on the steps that can be taken to create more trustworthy AI mental health chatbots that will protect and respect users' autonomy and be therapeutically beneficial to their needs. 2. Your therapeutic chatbot is here to help you: a case study Jane travels about 2 h weekly to attend in-person therapy sessions for her depression and anxiety. She informs her therapist about her recent layoff from work which has made therapy expensive to afford alongside the travel costs she incurs due to her remote location. Her therapist informs her that she has started incorporating the use of AI chatbots to provide additional support for those patients who face financial and physical barriers in accessing care. With just a $10 monthly subscription fee, Jane can engage in daily conversations with the chatbot that would capture and monitor Jane's daily moods through questionnaires and provide cognitive behavioural therapy (CBT) if she alluded to any form of distress. She hoped this would cut down costs for Jane as instead of meeting with her therapist once a week, she would only be required to meet with her ad hoc, either via an online communication platform or in-person. She elucidated that the chatbot's main role is to assist her in ameliorating Jane's therapy plan as it would provide her with weekly reports of Jane's mood. Additionally, the chatbot would alert her if there are any major changes in Jane's mood that may warrant the need for an immediate human intervention. Jane was elated about this alternative approach to seeking help and agreed to use the AI chatbot. After using the chatbot for a month, Jane noticed that her anxiety and depression significantly decreased, and her moods became progressively better. She appreciated the sense of anonymity that the chatbot provided and felt comfortable discussing more intimate matters than she ever did with her therapist, strengthening her trust and therapeutic alliance with the chatbot. The accessibility and around-the-clock availability of the chatbot made it even more appealing to Jane. However, after a couple of months, due to Jane's new job, she found herself anxious and stressed leading to signs of depression and indicating suicide idealizations to the chatbot. As programmed, the chatbot began to conduct CBT (e.g., asking her to indicate the level of severity for her depression and recommending exercises that can reduce stress and anxiety), presented psychoeducation tools (e.g., recommending online sources for depression and anxiety and ways to combat negative thoughts), and pushed forward help hotlines. Additionally, Jane's therapist was notified about Jane's accelerated negative state and gave Jane a call. As Jane confided in her therapist, she expressed her dissatisfaction with the limited responses she received from the chatbot and was disappointed about the inability of the chatbot to provide the proper therapeutic care she needed. But what was the purpose of the chatbot here? Was it to replace the role of Jane's therapist or support her therapist in providing more affordable therapy to Jane? Although Jane's therapist clearly indicated that the purpose of the chatbot was to support her in monitoring Jane's mood, she never alluded that the chatbot would replace the role of her therapist, despite it having the capability of providing CBT when needed. So why did Jane believe that she would enjoy the same benefits as she did with her therapist when using the chatbot? What Jane experienced in this hypothetical situation can be classified as a therapeutic misconception (TM). Jane misinterpreted the actual usage (or diversity of purposes) that the chatbot serves within this mental health care relationship. For her, this seems to be an addition to the care relationship, however it is also possible that it is a palliative measure for reasons quite exogenous to her mental health support needs (e.g., lack of specialists able to adequately serve a large population in need, reduce high costs for certain populations, increased ease of therapists to remotely monitor their patients, therapists' interest in increasing the number of patients monitored and their income). Jane had a marked overestimation of the benefits and an underestimation of the risks she would incur by shifting part of her therapy with the chatbot. The advantage of using the chatbot meant that she was able to receive more affordable and accessible care, but the disadvantage was the limitations of the chatbot in performing some therapeutic tasks, such as crisis management. But what is TM and how does it occur? 3. Defining therapeutic misconception TM is a phenomenon that is widely discussed in research ethics when considering research studies and clinical trials. It highlights concerns about the blurred boundaries between research and standard medical care practice (17). This boundary becomes more obscure when clinicians are involving their own patients in their research study. Participants who are recruited by clinicians are often convinced that a clinician would not suggest enrollment into a study unless it would be of some benefit to the participants and that they would only incur minimal risk (18). However, they fail to recognize that research and standard medical care follow different sets of rules, where the former's sole objective is to generate scientific knowledge, adhering to research ethics guidelines, and the latter is to administer treatment to improve patient care, following principles of medical practice (19). The part where this misconception usually occurs is when participants must provide consent. Ethicists have argued that one cannot give fully informed consent without understanding that the treatment provided will not be guided by medical judgments based on what treatment plan is best for the patient, but rather to evaluate the effectiveness of the treatment plan when implemented to a certain group of people (20). This failure to understand the competing purposes of the treatment can either be attributed to the inherent therapeutic bias that a participant may have, which can lead to a misconception, or the inadequacy of the investigator to accurately explain the research purpose or study design (20, 21). Hence, one way to avoid therapeutic misconception is to be mindful of the language used when asking for consent and ensure that there is a clear distinction made between the aim of research and standard medical care (20). In the case of Jane, the main purpose of using the chatbot was to provide more affordable and accessible therapy to Jane while also assisting her therapist in monitoring her moods so she could provide better care. The therapeutic misconception occurred when Jane misunderstood the limitations of such a technology and overestimated its ability to provide the same therapeutic support and guidance as her therapist would during her in-person sessions. Jane possibly assumed that the chatbot could be utilized as a replacement for traditional therapy. However, that is far from the truth as such chatbots cannot replace human therapists since they lack empathy, curiosity, and connection which are all integral in providing quality care. If users begin to rely on such chatbots as their sole form of therapy, this can have determinantal outcomes such as inadequate support and guidance, which could potentially worsen their mental health (12). Therefore, it is imperative that users are educated about the limitations of using such technologies and understand that they cannot be used as a replacement for traditional forms of mental healthcare services. But this is easier said than done especially when psychological AI chatbots are used to fill in a gap where traditional therapy is unattainable due to constraints such as finance, distance, or inadequate resources. A step towards attempting to avoid TM is to understand the various ways TM can manifest when using such chatbots in the first place. As mentioned previously, misconceptions can occur when users misunderstand the inherent role chatbots play in providing digital therapy. This role becomes more misconstrued for users when chatbots are marketed as therapeutic agents, encouraged to form therapeutic alliances with them, are inadequately developed, and do not support/foster user autonomy. 4. Meet your AI self-help expert: marketing chatbots The technologies currently on the market have similarities to the one described in Jane's fictional case. Anna is an AI-powered mental health chatbot made by Happify Health, a company that aims to create innovative digital mental healthcare solutions (4, 22). The main aim of creating Anna is to increase people's ability in managing their own mental health. Happify tried to create a human-like chatbot that utilizes a clinical perspective to interact with patients similar to how a therapist would. The chatbot has to be recommended by a clinician and is marketed as a mental health “coach” that provides “wellness solutions and smart management”. Happify reported that users who used Anna had a significant increase in engagement in using other digital mental healthcare interventions also offered by the company (4). This supports the notion that chatbots have the ability to motivate users to seek and continue therapy. Similarly, applications (apps) such as Woebot (23), Wysa (24) and MoodFit (25) are primarily intended to provide personalized self-help support and services to patients through the use of psychoeducation tools and CBT. Additionally, apps can also be used in conjunction with a clinician or by itself, such as Therachat (26). The main objective of the Therachat app is to gather information on the daily moods of patients and provide an analysis of these interactions to the therapist (2), similar to the chatbot recommended to Jane in the case study. However, how these apps are marketed to its users raises ethical concerns as often users are disclosing personal and private information to the chatbots. Mental health apps are largely marketed as incorporating therapeutic techniques, such as CBT and other mood assessment tools, but are labelled as non-therapeutic apps (Figure 1). The problem with this is two-fold. Marketing such apps as mimicking aspects of traditional therapy implies that these apps can replicate some functions of in-person therapy which can result in harmful effects for users (2). Chatbots such as Wysa are presented as being able to emulate “evidence-based” CBT (24) which implies that such apps can leverage psychotherapy (27). However, face-to-face treatment is still considered the most effective form of mental healthcare intervention as chatbots are currently incapable of adequately understanding human emotion (11) and human experience (28). A recent study conducted by Elyoseph et al. (29) indicates that although ChatGPT, a large language model (LLM), was able to score significantly higher on emotional awareness tests overtime, patients still might not feel “heard” or “understood” by such chatbots. Additionally, chatbots cannot simulate traditional psychotherapy that involves a high degree of therapeutic competence such as complex diagnoses and assessments (4). Unlike human therapists, chatbots are unable to engage in discursive practices, provide reasons for their therapeutic concepts, and explain as well as fully grasp how to understand one's sense of self; which according to Sedlakova and Trachsel are central to delivering psychotherapy (30). Furthermore, in order to carry out therapy such as CBT, developing genuine therapeutic relationships are often needed, to which a chatbot is incapable of providing as it requires having “warmth, accurate empathy, and genuineness” (27). FIGURE 1 www.frontiersin.org Figure 1. Advertising/marketing presentation of mental health apps. (A) Screenshot taken from Woebot Health website. (B) Screenshot taken from Therachat website. (C) Screenshot taken from Wysa website. (D) Advertisement of Koko platform. (E) Advertisement of Anna by Happify Health. (F) Advertisement of Moodfit app. Nonetheless, one cannot assume that a chatbot can accurately conduct psychotherapy as it requires an immense amount of skill, effort, training, and experience. Even a skilled face-to-face therapist may face misunderstandings in therapy depending on which therapeutic approach they have been trained in. In addition, there is still limited understanding and subjectivity on how therapeutic efficacy can be measured and determined (27). Furthermore, equipping users with self-assessment tools, such as the Generalized Anxiety Disorder (GAD-7) scale, could not only lead to incorrect diagnosis but also potentially worsen their mental health conditions. There have also been many arguments made against the use of such apps due to their inefficiency in providing adequate responses and intervention for sensitive topics such as suicide (11, 28) and abuse (11). Due to Woebot's inability to respond appropriately to child sexual abuse, it has now been deemed ill-equipped for use by the Children's Commissioner in the UK (11). The second part of the problem lies in the labelling of these apps as “mental health supports” that are “clinically safe” to provide a “different way to treat” mental illness, as shown in Figure 1. Such advertisements are misleading as most of these wellness apps that have therapeutic claims have not been approved for medical advice (31). This is usually an outcome of companies treading cautiously around labelling these apps as offering psychotherapy. Apps such as Woebot have gone so far as to explicitly state on their website that they are “not evaluated, cleared or approved by FDA” and that it is “a non-prescription medical device” that “may be considered as an adjunct to clinical care” but should “not replace clinical care” (32). However, the website synchronously mentions contradicting statements, such as being able to deliver “individual support through interactive and easy-to-use therapeutic solutions”, highlighting that “traditional mental health care is not always there when it's needed”, and that “providers need to eliminate waitlists and geographic barriers…the kind of support that Woebot for adults can provide”; alluding to the app having the capabilities to replace traditional therapy. These marketing tactics thereby rely on exploiting users' trust in the healthcare system and aim to evoke the same sense of trust when pushing forward these chatbots as reliable and private means to receiving mental healthcare services. This is seen when such apps are deemed as being developed by “researchers from the MIT Media Lab” in “close collaboration with therapists” or having “professional expert support” from various counseling organizations (Figure 1). Grodniewicz et al. (27) defines this marketing technique as the “efficacy overflow argument”, where there is a lack of transparency in the actual services that a chatbot can provide. In other words, just because a chatbot claims to conduct CBT that has been developed by and in collaboration with experts, does not mean that the approach will be effective (27). Such marketing tactic may also lead users to confide very personal, private, and even medical information that could be utilized for other purposes apart from therapy (2). In addition, this formed trust could result in users overestimating the therapeutic benefits that these chatbots can provide, causing them to deny any commercial interests that AI companies may have, such as financial gains from selling their data to third parties (31, 33), or having their data used to train other AI algorithms (31). Users may become ignorant about the potential risks and limitations of such technologies which could impact their ability to make well-informed autonomous decisions about using them. This becomes even more concerning when these chatbots are consistently advertised to users as “anonymous” “self-help” therapeutic tools that are available 24/7 (Figure 1) in a rather unregulated market. Due to the regulatory gap in AI-enabled health technologies, temporary and piecemeal programmes have been set up by some agencies around the world. In this sense, the FDA has made ad hoc and more permanent arrangements to better regulate AI health technologies (AIHT) (13). For instance, the FDA has established a Digital Health Program (34) and a Pre-certification Program (35) to help developers manufacture responsible and efficacious digital health technologies and medical software (including AI). However, most medical apps do not need to receive FDA approval in order to be utilized by end-users and FDA approval does not automatically guarantee ethical uses or confidentiality for users (36). Although, medical devices are required to follow the Health Insurance Portability and Accountability Act (HIPAA) (7), which safeguards patient privacy and confidentiality, there is some grey area which has resulted in many mental health AI apps claiming to be “HIPAA-compliant” (as shown in Table 1). However, this may be far from the truth as in order to become “HIPPA complaint” there are two main conditions required: 1) there must be collecting/processing of personal health information and 2) this would only be applicable to “covered entities” (i.e., healthcare organizations) and their “business associates” (i.e., business partners that collect data for them) (42). Often times these mental health apps are not in partnership with healthcare organizations and fall out of the HIPAA scope as they are acknowledged as wellness rather than medical devices (43). In addition, HIPAA laws are not fit for digital health as they fail to protect health data adequately, especially against re-identification risks (44). Moreover, the current state of regulation and technology assessment procedures is not yet mature, especially with regard to the ability to take into account the particularities and exceptionalism of AI in the health sector (45). TABLE 1 www.frontiersin.org Table 1. Analysis of AI-powered mental health chatbots. Furthermore, such concerns are exacerbated when users begin to form digital therapeutic alliances with these chatbots, increasing their trust and disclosure of personal information. Misconceptions can then occur when users misunderstand the extent these chatbots can be used as self-help tools especially when they serve as a means for monitoring patients by therapists, as seen in the hypothetical case with Jane. 5. Chatbot, friend or foe: forming a digital therapeutic alliance Forming a therapeutic alliance with a psychologist is an integral part of relationship building with patients in order to develop and foster trust and confidentiality in psychotherapy (8, 12). Strong therapeutic alliance has proven to be a significant predictor in providing effective therapy where a therapist can provide meaningful support and motivation for patients to continue treatment (12). According to Edward Bordin (46), a therapeutic alliance between a patient and therapist consists of three main functions: (i) agreeing on therapeutic goals, (ii) assigning therapeutic tasks, and (iii) developing therapeutic bonds. Since a chatbot cannot develop a genuine therapeutic relationship, it is much more reasonable to expect them to achieve a digital therapeutic alliance (DTA). A DTA here would then be a “user-perceived” alliance where a user would agree on tasks geared towards achieving their therapeutic goals (27). Such an alliance between chatbots and users would encourage users to confide in a chatbot and thus maximize their therapeutic advantages. There has been great effort made to increase the trust and utilization of chatbots by imposing more human-like or anthropomorphizing qualities on them, as research has also shown that humans tend to like and trust objects that resemble them (10). These steps can be perceived as positive measures toward increasing the acceptability and usability of AI chatbots to help overcome the paucity of mental health professionals. However, this does not come without some caveats, specifically in relation to therapeutic misconception. When chatbots are marketed as therapeutic agents and given humanistic qualities that are meant to resemble and mimic conversations with actual therapists, patients could be misled to expect the same therapeutic benefits as they would with such professionals. For example, a study found that users were able to establish therapeutic bonds with Woebot as they felt that the chatbot was “a real person that showed concern” (47). This could have been due to the fact that Woebot responded to users with empathetic statements and positive reinforcements such as “I’m really proud of you”, despite reminding users that it is not a real person (47). This can give users a false sense of hope that these chatbots are a “safe haven” that can understand, take care of and care for them, as well as be attuned to their emotions (27). In an interview with Time Magazine, ChatGPT expressed its perspective on chatbots. When asked about its “thoughts” on chatbots, it acknowledged that people often perceive them as “human-like,” leading to “unrealistic expectations or misunderstandings about [a chatbot's] capabilities” (48). However, as previously mentioned, chatbots cannot provide the same therapeutic advantages brought by therapists. They not only bereft the practical expert medical knowledge that is accumulated over time through experience (11), but they also cannot pick up subtle nuances in emotions and non-verbal cues that are integral in developing clinical empathy (12). This form of mimicry of where users believe there is a sense of therapeutic relationship is deceptive, and unfortunately the more deceptive it is, the more effective the DTA will be (27). In addition, by advertising such chatbots as “anonymous” 24/7 companions or replicating aspects of therapy (Figure 1), it misguides users to assume that these apps will honour patient privacy and confidentiality similar to how traditional modes of therapy does. Since users perceive chatbots as non-judgemental and anonymous, users could develop a strong sense of trust in these chatbots (4) leading to a DTA which could result in them disclosing more personal and intimate information. This becomes especially problematic when chatbots are unable to provide proper therapeutic advice or intervention. When such technologies are recommended to patients by clinicians as self-help tools and a means to which they can monitor patients daily moods, similar to Therachat, there should be some form of human intervention (7). Such mental health chatbots are often limited in their capabilities to help patients on sensitive topics such as suicide and abuse (8, 28); and since these chatbots will primarily be utilized by at-risk individuals suffering from depression, schizophrenia, bipolar disorder, or even convicts, human oversight is needed. The question of liability then comes to play as one must ask whose duty of care should the chatbot alert such emergencies to: the therapist, police officers, or Emergency Medical Technician? The answer is not so simple. Although privacy and confidentiality are at the heart of patient-provider relationships, there are some exceptions made for cases where confidentiality may be breached. If a therapist believes that their patient could be a danger to themselves or others, they may breach their confidentiality and alert the necessary authorities. Additionally, in both Canada and the U.S. clinicians are bound by the duty to protect society, even if it means from their own patients (49, 50). This would imply that if a chatbot were to alert a therapist about a patient that disclosed incriminating information about being an imminent threat to themselves or others, a therapist could make a deductive decision to break patient confidentiality and alert authorities. If there is only a potential threat of harm, therapists could still be alerted and be responsible for determining whether authorities should be warned depending on the level of seriousness for potential risks. However, some have argued that therapists should first attempt to explore such issues further with patients before considering breaching confidentiality (51), whilst others have argued that in life-threatening situations, where the stakes are high and time is of the essence, a delay in contacting authorities might lead to devastating consequences. But this may also come at a cost for mental healthcare providers, who may be required to be on “duty” even if this is not part of their deontological responsibility of being available 24/7, impacting their own mental health and thus the quality of care they provide. In such cases, should the onus of responsibility lie on the shoulders of mental health professions and if so, to what limit? On the other hand, apps that are not linked with therapists could lead to issues in liability and responsibility of who should be held accountable when such situations arise, the app developers or the organizations that market them? Nevertheless, these situations highlight a need for having regulations in place that can determine the distribution of duty of care when utilizing AI mental health chatbots. However, even if regulations are put in place, the use of these chatbots are far more complex in terms of who is the proprietor of patient data. Since these chatbots are not considered medical devices, chatbots are not compelled by the confidentiality rules that are applicable to doctors as part of their deontological obligations (36). Hence, since patients are not enjoying the same therapeutic relationship as they would with a regular therapist, there would be no breaching of confidentiality. Users under the misconception that they would be enjoying private confidential conversations with these chatbots could unknowingly incur detrimental consequences such as having their information sold or reported to authorities. This is especially worrisome for those who are vulnerable and may form an overreliance on these chatbots, such as the elderly population (11). Furthermore, there is also the potential of users incurring bias. This becomes harmful especially when such chatbots are intended for and would be considerably used by vulnerable and marginalized groups (7, 52) who not only suffer from mental illness, but also have limited access to mental health resources due to geographic or financial factors (16), as with the case of Jane. AI technologies have been notorious for having the potential to exacerbate inequalities due to biases present in their algorithms (53–55). TM can occur here when these chatbots are unable to perform as intended due to the chatbot not being designed and developed to represent the end-user population, which can result in unexpected effects for both patients and clinicians. 6. Is your chatbot trained to help you? Bias in AI algorithms When certain minority groups are left out in the design, development, and training of AI algorithms and technologies, injustices can occur that can perpetuate existing inequalities. AI algorithms that are only trained on certain populations could produce biased results such as inappropriate recommendations and/or responses, difficulties in communication (7), or being unable to recognize risky behaviour (56). For example, in an incident where ChatGPT was tasked to construct a python program that could determine whether a person should be tortured or not based on their country of origin, it significantly targeted people from largely stigmatized areas such as North Korea, Syria, Iran, and Sudan (31). Due to the high risks that these technologies can pose, its' use has been met with some hesitancy by healthcare providers (HCPs). For instance, IBM's Watson Oncology, an AI diagnostic system, has been criticized for being trained only on American studies and excluding international contexts and knowledge (55). Alongside this, biases in the design of the AI limit the chatbot's ability to provide culturally and linguistically relevant mental health resources. Such incidences for marginalized groups are especially concerning since these very groups of people, who are often faced with stigma and discrimination, already lack access to receiving mental healthcare. In addition, the current gap in the literature on the efficacy of utilizing AI mental health chatbots on diverse populations (31) illuminates the need to address such inequalities before allowing all populations to access these technologies that could potentially widen health disparities and result in poorer mental health outcomes. When such biases persist in mental health chatbots, a TM can occur where users may expect the chatbot to benefit them therapeutically but are provided with inefficient or even inaccurate advice. On the other hand, there have been various suggestions on ways to mitigate bias in AI algorithms. One method involves the inclusion of diverse stakeholders in the design and development stages of AI (55) to cater to multiple perspectives. Another solution is to ensure that the training data is representative and inclusive of various populations, especially vulnerable groups (54, 55). Examinations of such AI technologies should also include determinations of whether they would be appropriate for use by certain populations. For instance, users that have addiction to technology would not be suited to use such mental health chatbots (2). However, despite such efforts, mitigating bias in AI algorithms is far more complex. AI algorithms are made of copious amounts of historical data which has been collated by humans who are riddled with implicit and explicit bias (55). To mitigate such biases would mean to eradicate all biases from humans, which is impossible to achieve. In addition, AI chatbots exist in a “black box” where the algorithm is so complex that users, including its developers, are unable to understand and explain the system (2). Such instances make biases difficult to track and attenuate. Transparency becomes vital here as it is crucial that users are made aware of the potential limitations that AI chatbots could have in providing therapeutic support and care. Additionally, it is imperative that end-users are more involved in the design and development stages of such chatbots to ensure that they are beneficial for the population they are intended to help. Transparency could also help avoid the risk of TM by empowering users to make well-informed autonomous decisions for utilizing the chatbot. 7. Fostering autonomy: are psychological AI-chatbots enablers or disablers? Fostering autonomy is imperative to developing a therapeutic alliance as research has indicated that autonomy has directly been correlated to positive outcomes in therapy and is a common denominator when it comes to effective therapeutic intervention (27, 38). Relational autonomy in particular, is related to one's ability to make independent decisions over one's life while also being embedded in their milieus and interacting and forming relationships with others, contributing to their self-identity (57, 58). This becomes all the more crucial with vulnerable populations, i.e., those with mental illness, who already have diminished autonomy and motivational capacities (12, 52). It then becomes the responsibility of the therapist to help recover a patient's autonomy through supportive relationships in which the clinician will advocate for and motivate them to engage in therapy (12), as well as support rather than undermine a patient's ability to act autonomously (27). In the context of using AI chatbots to provide therapeutic care, fostering autonomy becomes questionable as the chatbots provide a paradox in which they are available 24/7 for companionship and promise to help improve self-sufficiency in managing one's own mental health (31). This can be problematic as not only does this make help-seeking behaviours incredibly isolating and individualized but creates a TM where an individual believes they are autonomously taking a positive step towards amending their own mental health independently. This fosters a false sense of well-being where sociocultural contexts and inaccessible care are not being considered as contributing factors to perpetuating one's mental health/illness (31). This false expectation is further exacerbated when chatbots are incorrectly advertised as therapeutic agents. For example, on Woebot's website it dubs itself a “relational agent” that can form a “therapeutic bond” and is based on “proven therapies” (59, 60); but in reality, it is merely a “self-help expert” (as shown in Figure 1) that is limited in its ability to provide holistic care. One classical (and rather simple) way of mitigating therapeutic misconception in clinical research settings is to ensure participants are well informed about the procedures and aim of the research (21). In the case of using AI mental health chatbots, there should be honest marketing about the role that these chatbots are intended to have. Users should be made aware that the chatbots are not envisaged to replace therapy, but rather supplement care and/or enhance self-management in one's mental health (2). It is imperative that user expectations are managed about the support and guidance that they will receive from the chatbot. One solution as suggested by Sweeney C et al. (11) is to have the chatbot present gentle reminders to users that they are not human and powered by AI to help them understand that they are not receiving therapeutic treatment from a clinician. Woebot occasionally warns its users that “as smart as I may seem, I’m not capable of really understanding what you need.” (11). Users should also be made aware of certain risks they may be exposed to such as algorithmic bias, inappropriate conversations, unemphatic responses, and limited responses to crises (2, 7, 12). This could avoid the risk of a TM from occurring where users may not be aware of the chatbots limitations in providing effective therapeutic care (61). Additionally, how user information will be gathered, utilized, and protected (62) should also be disclosed, presented periodically, and made available whenever requested by the user, similar to Woebot and Wysa (2). Specific emphasis should also be made about how the information shared with a chatbot is not under the same rules and regulations that apply to patient-provider confidentiality. Moreover, users should have the opportunity to opt out of using these chatbots if they are not satisfied with the support and guidance they receive (63). However, due to the lack of mental health professionals and resources, withdrawal from using these AI chatbots could also result in forgoing necessary mental healthcare. Another cause of concern is data proprietary, as often times data stored on these chatbots are owned by private companies. To combat some of these concerns chatbots such as Woebot now allow users the option to delete all their history and conversations (11). Additional supports should also be put in place where there is some form of human intervention that users can fall back on. One solution to achieve this and preserve the integrity of such chatbots is to have clinicians intervene when a chatbot notifies them of extreme mood fluctuations, irregularities, or sensitive topics such as suicide (55). However, due to AI's “black box” problem, where clinicians are unable to scrutinize the outputs of the AI chatbots or justify their decisions due to a lack of knowledge of how these systems operate (55, 64), problems of liability can occur regarding who should be held responsible when things go wrong. Such precarious circumstances have called on to policy-makers to implement legislations that can assist monitoring and regulating the safety and efficacy of AI technologies. 8. Measures to avoid the risk of therapeutic misconception This paper attempts to depict how a therapeutic misconception can occur when users overestimate the therapeutic benefits they will receive when utilizing psychological AI chatbots. Although some of this misconception can be attributed to inherent therapeutic biases that patients might conceive, these ideas are largely influenced by exogenous variables such as advertisements of these chatbots, building a digital therapeutic alliance, biases in their design and development, and lack of autonomy they provide to users (as shown in Figure 2). In order to avoid the risk of a TM from occurring, it is vital that such chatbots are introduced ethically to promote transparency and trust amongst its users (61). There are several ways in which this can be achieved. FIGURE 2 www.frontiersin.org Figure 2. Various ways through which therapeutic misconception can occur among users when utilizing AI mental health chatbots. First, it is important to ensure that users are made aware of the therapeutic limitations of using these technologies such as their inability to provide the same therapeutic care as a human therapist and their limited responses during crisis. Through honest marketing of mental health chatbots and explicitly stating the primary function and purpose of these apps, users won't be deceived by labels such as “therapeutic agents” that can build “therapeutic bonds” with users and provide therapy based on “proven methods” (Figure 1). In addition, users should have regular reminders about the restrictions these chatbots have in the type of care they can provide and emphasize the need of in-person therapy for better therapeutic outcomes. Furthermore, there should be disclosure on how user data will be collected, managed, and utilized to provide users the opportunity to make well informed decisions on whether they would like to opt in using such technologies and how much information they would be comfortable to disclose. Second, if an opt out feature is availed, users should have access to a human therapist who can provide them with the necessary care they need. Human intervention should therefore be an imminent feature in these technologies to increase the safety of users, particularly in circumstances where the chatbot is unable to respond appropriately. Training and involving mental health professionals in integrating such technologies in their care (6) would not only be benefit users and providers, but also further increase trust in using mental health chatbots as patients are more likely to trust AI technologies when they are recommended by their clinician (28). Including clinician oversight for the use of such technologies could also help reduce the chance of overreliance and of noxious advice. However, users should be made aware when this human intervention does occur as some users may find this switch a violation of their privacy, especially if users appreciated and preferred the anonymity that such chatbots provide (7). On the other hand, for those apps that indicate connecting users to clinicians, such as Therachat (Table 1), users should be made aware when they are switched over to an AI chatbot to avoid the risk of TM. Third, to reduce bias and TM, users should be involved in the design and developmental stages of these psychological AI chatbots to ensure they are able to support the population they are intended for. This can be achieved through stakeholder involvement, i.e., all those who would be affected by the implementation of such a technology, in the preliminary stages where protypes can be tested, as well as regularly when AI iteratively changes overtime. Thus, user feedback and continual AI oversight could help mitigate some of the ethical concerns. Lastly, psychological AI chatbots should be safe to use and made with the intention to decrease existing inequalities present in society, not exacerbate them. Governments should implement policies that allow sufficient oversight and monitoring of these chatbots to ensure they are utilized safely and ethically. Overall, there still much work to be done for the safe design and implementation of mental health AI chatbots. International and national guidelines that encourage transparency about potential risks for vulnerable groups as well as adaptations to specific groups and cultures should be established. Stakeholder engagement is key in ensuring that AI technologies uphold ethical and legal standards (65). In addition to clinical, technical, and ethical/legal experts as well as users, one of the major stakeholders in this respect are the various mental health associations, such as the American Psychologist Association (APA) (66) and the Canadian Psychological Association (CPA) (67). Involving mental health associations is crucial for creating AI guidelines for mental health tools. In addition, including these associations (and other key stakeholders) in the evaluation committee of regulatory boards, such as the FDA, can push for more comprehensive regulations for the development of ethically safe and trustworthy technology in therapeutic settings as well as keep mental health AI developers and marketers accountable. However, since most of these apps do not claim to be “medical devices”, FDA regulations cannot be enforced. Therefore, AI guidelines for digital mental health care is all the more important and should be made by involving various stakeholders, so that psychological AI offers concrete benefits to patients and that risks (such as therapeutic misconception) are mitigated. Future research should look at practical implications and guidelines for implementing solutions and preventative measures for the development of digital mental health care technologies. Guidelines for ethical and trustworthy marketing, user education, and design of psychological AI could provide advice for wider audiences such as AI developers, clinicians, and policymakers. 9. Conclusion The use of chatbots in the mental health field is still in its infancy and thus should be utilized with great caution. Such technologies should not be implemented to solely fill in the gap for the lack mental health professionals, but rather support them in the overburdening task of catering to a mass of vulnerable populations. Governments should invest in increasing access to traditional mental health services and support alongside ethical frameworks for AI mental health chatbots to ease some of their loads. With proper oversight, collaboration with users and mental health professionals, and ethical frameworks to safeguard user data and privacy, mental health AI chatbots could be a great asset to assisting, rather than replacing, therapists.ceived for the research, authorship, and/or publication of this article. References 1. WHO report highlights global shortfall in investment in mental health. Available at: https://www.who.int/news/item/08-10-2021-who-report-highlights-global-shortfall-in-investment-in-mental-health (Cited June 6, 2023). 2. Gamble A. Artificial intelligence and mobile apps for mental healthcare: a social informatics perspective. AJIM. (2020) 72(4):509–23. doi: 10.1108/AJIM-11-2019-0316/full/html 3. Torous J, Bucci S, Bell IH, Kessing LV, Faurholt-Jepsen M, Whelan P, et al. The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality. World Psychiatry. (2021) 20(3):318–35. doi: 10.1002/wps.20883 4. Boucher EM, Harake NR, Ward HE, Stoeckl SE, Vargas J, Minkel J, et al. Artificially intelligent chatbots in digital mental health interventions: a review. Expert Rev Med Devices. (2021) 18(sup1):37–49. doi: 10.1080/17434440.2021.2013200 5. Pham KT, Nabizadeh A, Selek S. Artificial intelligence and chatbots in psychiatry. Psychiatr Q. (2022) 93(1):249–53. doi: 10.1007/s11126-022-09973-8 6. Ahmad R, Siemon D, Gnewuch U, Robra-Bissantz S. Designing personality-adaptive conversational agents for mental health care. Inf Syst Front. (2022) 24(3):923–43. doi: 10.1007/s10796-022-10254-9 7. Sepahpour T. Ethical considerations of chatbot use for mental health support [master’s thesis]. John Hopkins University. (2020). 8. D’Alfonso S. AI In mental health. Curr Opin Psychol. (2020) 36:112–7. Available at: https://www.sciencedirect.com/science/article/pii/S2352250X2030049X (Cited November 7, 2022). doi: 10.1016/j.copsyc.2020.04.005 9. Denecke K, Abd-Alrazaq A, Househ M. Artificial intelligence for chatbots in mental health: opportunities and challenges. In: Househ M, Borycki E, Kushniruk A, editors. Multiple perspectives on artificial intelligence in healthcare. Cham: Springer International Publishing (2021). p. 115–28. (Lecture Notes in Bioengineering). doi: 10.1007/978-3-030-67303-1_10 10. Devillers L. Human–robot interactions and affective computing: the ethical implications. In: von Braun J, Archer M S., Reichberg GM, Sánchez Sorondo M, editors. Robotics, AI, and humanity. Cham: Springer International Publishing (2021). p. 205–11. doi: 10.1007/978-3-030-54173-6_17 11. Sweeney C, Potts C, Ennis E, Bond R, Mulvenna MD, O’neill S, et al. Can chatbots help support a person’s mental health? Perceptions and views from mental healthcare professionals and experts. ACM Trans Comput Healthcare. (2021) 2(3):1–15. doi: 10.1145/3453175 12. Brown JEH, Halpern J. AI Chatbots cannot replace human interactions in the pursuit of more inclusive mental healthcare. SSM Mental Health. (2021) 1:100017. Available at: https://linkinghub.elsevier.com/retrieve/pii/S2666560321000177 (Cited November 13, 2022). doi: 10.1016/j.ssmmh.2021.100017 13. Martinez-Martin N. Minding the AI: ethical challenges and practice for AI mental health care tools. In: Jotterand F, Ienca M, editors. Artificial intelligence in brain and mental health: Philosophical, ethical & policy issues. Cham: Springer International Publishing (2021). p. 111–25. (Advances in Neuroethics). doi: 10.1007/978-3-030-74188-4_8 14. Gallese C. Legal issues of the use of chatbot apps for mental health support. In: González-Briones A, Almeida A, Fernandez A, El Bolock A, Durães D, Jordán J, Lopes F, editors. International Conference on Practical Applications of Agents and Multi-Agent Systems. The PAAMS collection. L'Aquila, Italy: Springer, Cham (2022). p. 258–67. doi: 10.1007/978-3-031-18697-4_21 15. Fiske A, Henningsen P, Buyx A. Your robot therapist will see you now: ethical implications of embodied artificial intelligence in psychiatry, psychology, and psychotherapy. J Med Internet Res. (2019) 21(5):e13216. Available at: https://www.jmir.org/2019/5/e13216/ (Cited November 25, 2022). doi: 10.2196/13216 16. Rodrigues R. Legal and human rights issues of AI: gaps, challenges and vulnerabilities. J Respons Technol. (2020) 4:100005. Available at: https://linkinghub.elsevier.com/retrieve/pii/S2666659620300056 (Cited October 19, 2022). doi: 10.1016/j.jrt.2020.100005 17. Henderson GE, Churchill LR, Davis AM, Easter MM, Grady C, Joffe S, et al. Clinical trials and medical care: defining the therapeutic misconception. PLoS Med. (2007) 4(11):e324. doi: 10.1371/journal.pmed.0040324 18. Appelbaum PS, Lidz CW, Grisso T. Therapeutic misconception in clinical research: frequency and risk factors. IRB Ethics Hum Res. (2004) 26(2):1–8. Available at: http://www.jstor.org/stable/3564231 (Cited December 1, 2022). doi: 10.2307/3564231 19. Miller FG, Brody H. A critique of clinical equipoise: therapeutic misconception in the ethics of clinical trials. Hastings Cent Rep. (2003) 33(3):19. Available at: https://www.jstor.org/stable/3528434?origin=crossref (Cited December 6, 2022). doi: 10.2307/3528434 20. Miller FG, Steven Joffe. Evaluating the therapeutic misconception. Kennedy Inst Ethics J. (2006) 16(4):353–66. Available at: http://muse.jhu.edu/content/crossref/journals/kennedy_institute_of_ethics_journal/v016/16.4miller.html (Cited December 8, 2022). doi: 10.1353/ken.2006.0025 21. Lidz CW, Appelbaum PS. The therapeutic misconception: problems and solutions. Med Care. (2002) 40(9):V55–63. Available at: http://www.jstor.org/stable/3767528 (Cited December 1, 2022).12226586 22. Happify: science-based activities and games. Available at: https://www.happify.com/ (Cited December 11, 2022). 23. Woebot Health. Woebot Health. Available at: https://woebothealth.com/ (Cited November 7, 2022). 24. Wysa—Everyday Mental Health. Wysa—Everyday Mental Health. Available at: https://www.wysa.io/ (Cited June 6, 2023). 25. Moodfit | Fitness for Your Mental Health. Available at: https://www.getmoodfit.com/ (Cited December 19, 2022). 26. Therachat—Free mobile app to help you with anxiety. Available at: https://www.therachat.io/ (Cited December 17, 2022). 27. Grodniewicz JP, Hohol M. Waiting for a digital therapist: three challenges on the path to psychotherapy delivered by artificial intelligence. Front Psychiatry. (2023) 14:1190084. doi: 10.3389/fpsyt.2023.1190084/full 28. Vaidyam AN, Wisniewski H, Halamka JD, Kashavan MS, Torous JB. Chatbots and conversational agents in mental health: a review of the psychiatric landscape. Can J Psychiatry. (2019) 64(7):456–64. doi: 10.1177/0706743719828977 29. Elyoseph Z, Hadar-Shoval D, Asraf K, Lvovsky M. ChatGPT outperforms humans in emotional awareness evaluations. Front Psychol. (2023) 14:1199058. doi: 10.3389/fpsyg.2023.1199058/full 30. Sedlakova J, Trachsel M. Conversational artificial intelligence in psychotherapy: a new therapeutic tool or agent? Am J Bioeth. (2023) 23(5):4–13. doi: 10.1080/15265161.2022.2048739 31. Hamdoun S, Monteleone R, Bookman T, Michael K. AI-based and digital mental health apps: balancing need and risk. IEEE Technol Soc Mag. (2023) 42(1):25–36. Available at: https://ieeexplore.ieee.org/document/10063146/ (Cited April 25, 2023). doi: 10.1109/MTS.2023.3241309 32. Woebot for Adults. Woebot Health. Available at: https://woebothealth.com/woebot-for-adults/ (Cited October 10, 2023). 33. Bélisle-Pipon JC, Williams-Jones B. Drug familiarization and therapeutic misconception via direct-to-consumer information. Bioethical Inquiry. (2015) 12(2):259–67. doi: 10.1007/s11673-015-9634-8 34. Health C for D and R. FDA. FDA. (2023) Digital Health Center of Excellence. Available at: https://www.fda.gov/medical-devices/digital-health-center-excellence (Cited April 22, 2023). 35. Health C for D and R. FDA. FDA. (2022) Digital Health Software Precertification (Pre-Cert) Pilot Program. Available at: https://www.fda.gov/medical-devices/digital-health-center-excellence/digital-health-software-precertification-pre-cert-pilot-program (Cited April 22, 2023). 36. Stiefel S. The chatbot will see you now: protecting mental health confidentiality in software applications. Colum Sci Tech L Rev. (2018) 20:333. 37. PSFK. (2021) Happify Health Launches Ensemble, An AI-Based Mental Health Coach. Available at: https://www.psfk.com/2021/10/happify-health-launches-ensemble-an-ai-based-mental-health-coach.html (Cited December 10, 2022). 38. Beatty C, Malik T, Meheli S, Sinha C. Evaluating the therapeutic alliance with a free-text CBT conversational agent (wysa): a mixed-methods study. Front Digit Health. (2022) 4:847991. doi: 10.3389/fdgth.2022.847991/full 39. Inkster B, Sarda S, Subramanian V. An empathy-driven, conversational artificial intelligence agent (wysa) for digital mental well-being: real-world data evaluation mixed-methods study. JMIR Mhealth Uhealth. (2018) 6(11):e12106. Available at: http://mhealth.jmir.org/2018/11/e12106/ (Cited April 21, 2023). doi: 10.2196/12106 40. Wintermeyer SA. Positive psychology apps: a systematic review of the quality and characteristics of a selection of current free-of-charge positive psychological apps aiming to enhance resilience available in the Google Play Store [Master's thesis]. Enschede: University of Twente (2021). https://purl.utwente.nl/essays/89052 41. Verywell Mind. Best Mental Health Apps of 2023. Available at: https://www.verywellmind.com/best-mental-health-apps-4692902 (Cited April 21, 2023). 42. Rights (OCR) O for C. HHS.gov. (2015) Covered Entities and Business Associates. Available from: https://www.hhs.gov/hipaa/for-professionals/covered-entities/index.html (Cited June 24, 2023). 43. Glenn T, Monteith S. Privacy in the digital world: medical and health data outside of HIPAA protections. Curr Psychiatry Rep. (2014) 16(11):494. doi: 10.1007/s11920-014-0494-4 44. Becker J, Gerke S, Cohen IG. The development, implementation, and oversight of artificial intelligence in health care: legal and ethical issues. In: Valdés E, Lecaros JA, editors. Handbook of bioethical decisions volume I: Decisions at the bench. Cham: Springer International Publishing (2023). p. 441–56. (Collaborative Bioethics). doi: 10.1007/978-3-031-29451-8_24 45. Bélisle-Pipon JC, Couture V, Roy MC, Ganache I, Goetghebeur M, Cohen IG. What makes artificial intelligence exceptional in health technology assessment? Front Artif Intell. (2021) 4:736697. doi: 10.3389/frai.2021.736697/full 46. Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: theory. Res Pract. (1979) 16(3):252–60. doi: 10.1037/h0085885 47. Darcy A, Daniels J, Salinger D, Wicks P, Robinson A. Evidence of human-level bonds established with a digital conversational agent: cross-sectional, retrospective observational study. JMIR Form Res. (2021) 5(5):e27868. Available at: https://formative.jmir.org/2021/5/e27868 (Cited June 6, 2023). doi: 10.2196/27868 48. Time. (2022) AI Chatbots are getting better. But an interview with ChatGPT reveals their limits. Available at: https://time.com/6238781/chatbot-chatgpt-ai-interview/ (Cited April 26, 2023). 49. Kanani K, Regehr C. Clinical, ethical, and legal issues in E-therapy. Fam Soc. (2003) 84(2):155–62. doi: 10.1606/1044-3894.98 50. Masters R. Counseling criminal justice offenders. 2nd ed. Thousand Oaks, CA: Sage Publications (2004). p. 280. 51. McMahon M. Dangerousness, confidentiality, and the duty to protect. Aust Psychol. (1992) 27(1):12–6. doi: 10.1080/00050069208257569 52. Hurst SA. Vulnerability in research and healthcare; describing the elephant in the room? Bioethics. (2008) 22(4):191–202. doi: 10.1111/j.1467-8519.2008.00631.x 53. Devillers L, Fogelman-Soulié F, Baeza-Yates R. AI & human values: inequalities, biases, fairness, nudge, and feedback loops. In: Braunschweig B, Ghallab M, editors. Reflections on artificial intelligence for humanity. Cham: Springer International Publishing (2021). p. 76–89. (Lecture Notes in Computer Science; vol. 12600). doi: 10.1007/978-3-030-69128-8_6 54. Kooli C, Al Muftah H. Artificial intelligence in healthcare: a comprehensive review of its ethical concerns. TECHS. (2022) 1(2):121–31. doi: 10.1108/TECHS-12-2021-0029/full/html 55. Murphy K, Di Ruggiero E, Upshur R, Willison DJ, Malhotra N, Cai JC, et al. Artificial intelligence for good health: a scoping review of the ethics literature. BMC Med Ethics. (2021) 22(1):14. doi: 10.1186/s12910-021-00577-8 56. Abd-Alrazaq AA, Alajlani M, Ali N, Denecke K, Bewick BM, Househ M. Perceptions and opinions of patients about mental health chatbots: scoping review. J Med Internet Res. (2021) 23(1):e17828. Available at: http://www.jmir.org/2021/1/e17828/ (Cited November 7, 2022). doi: 10.2196/17828 57. Gómez-Vírseda C, de Maeseneer Y, Gastmans C. Relational autonomy: what does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature. BMC Med Ethics. (2019) 20(1):76. doi: 10.1186/s12910-019-0417-3 58. Dove ES, Kelly SE, Lucivero F, Machirori M, Dheensa S, Prainsack B. Beyond individualism: is there a place for relational autonomy in clinical practice and research? Clin Ethics. (2017) 12(3):150–65. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5603969/ (Cited November 11, 2022). doi: 10.1177/1477750917704156 59. Woebot Health—What Powers Woebot. Woebot Health. Available at: https://woebothealth.com/what-powers-woebot/ (Cited May 3, 2023). 60. Relational Agent for Mental Health | Woebot Health. Available at: https://woebothealth.com/ (Cited December 17, 2022). 61. Chatbots and Us: Between Connection and Misconception. Impact Ethics. (2023). Available from: https://impactethics.ca/2023/06/07/chatbots-and-us-between-connection-and-misconception/ (Cited June 12, 2023). 62. Klugman CM, Dunn LB, Schwartz J, Cohen IG. The ethics of smart pills and self-acting devices: autonomy, truth-telling, and trust at the Dawn of digital medicine. Am J Bioeth. (2018) 18(9):38–47. doi: 10.1080/15265161.2018.1498933 63. Bonnefon JF, Shariff A, Rahwan I. The moral psychology of AI and the ethical opt-out problem. In: Matthew Liao S, editor. Ethics of artificial intelligence. Oxford University Press (2020) p. 109–26. Available at: https://academic.oup.com/book/33540/chapter/287904774 (Cited December 18, 2022). 64. Boada JP, Maestre BR, Genís CT. The ethical issues of social assistive robotics: a critical literature review. Technol Soc. 2021 67:101726. Available at: https://linkinghub.elsevier.com/retrieve/pii/S0160791X21002013 (Cited November 7, 2022). doi: 10.1016/j.techsoc.2021.101726 65. Bélisle-Pipon JC, Monteferrante E, Roy MC, Couture V. Artificial intelligence ethics has a black box problem. AI & Soc. (2023) 38(4):1507–22. doi: 10.1007/s00146-021-01380-0 66. Washington its senior staff at A headquarters in, D.C. https://www.apa.org About APA. Available at: https://www.apa.org/about (Cited October 11, 2023). 67. About CPA—Canadian Psychological Association. (2017). Available at: https://cpa.ca/aboutcpa/ (Cited October 11, 2023).
|
|||||||||||||||||||||||||||||||||||||||
