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I just got back from my 40+2 years High School reunion.  It was the ultimate connection and we all agreed we were so very fortunate to have shared a relatively innocent, prosperous and peaceful time in our early lives together.  There's a bond there that is uncanny - the person gets you at your core.  There is no language needed.  They knew you at the essence of you-ness.  It's like the missing tree or something. Some of us had divorced parents, but very few growing up in the 70's.  I was one of them and it has haunted me for much of my life.  I often felt "less than" even though I appeared to have it all.  Of course none of that really matters anymore.  We have grown old now - empty-nesters mostly.  Everyone has faced down hardships by this point in their lives. One close classmate was missing, battling cancer.  Several have died.  I recently lost my 2nd parent. It's not news that divorce is the gift that just keeps giving.  I have worked with this for all of my career.  Many will say, well the kids are older, so it's OK. Probably not.  Even young adults have feelings!!  I often hear them in therapy saying: major conflicts continue. And that, it turns out from the research, is the clincher.  Unlike losing a parent, you simply keep them and their problems for the rest of your life; IT NEVER ENDS!!!  Therefore, the work in therapy does not have a time limit. Just because you're "emancipated" at 18 or 21 does not mean you're free from childhood trauma, not even close.  That's just the beginning of often lifelong insecurity, worry, self-doubt, shame, worthlessness, confusion and more. Who will walk me down the aisle being just one of many. -It's important to go back to the time of the divorce with young adults, not to re-hash or re-traumatize but to understand just exactly what has changed in you, and the magnitude of that loss. -It's important to look at how you were "parentalized" while they were acting out - meaning did you have to take care of adult things as a child?  How did that work out? -It's important to acknowledge that it's on-going.  Every single decision and holiday is more fraught than before. -It's important to understand that you can't figure it out.  I tried for years a kind of mental trap: if I can just be smart enough to dissect what happened I would have some relief.  Not so much. -It's important to realize not only is it not your fault, but you weren't defective; they were. They owed you some stability.  It was their job.  Divorced parents seem to become wildly self-absorbed in the aftermath - making up for lost time.  Or, they go the other way and start hoovering you into their over-involvement.  Either way is an unnecessary extreme. As a young adult it's your job to individuate - separate from your parents.  How can you when they are failing social-emotionally?  If you're swimming and you need to turn, and there's no wall there to push off of, how can you accelerate? I know not every divorce is a disaster like my family's was. But it still hurts bad at ANY age.  There is no right age. So don't let anyone tell you, oh move on already.  Go back to your High School self and thank yourself for doing the best you could, before you knew what to do.  Everyone has a struggle, and the struggle is real.

Photo Credit @madgescottstudio I get no respect, said Jackie Mason the comedian.  That's how I feel.  Oh mom's in the basement working with clients. What an easy gig!!  Just chat with people on the phone or zoom or in person, like a friend!  Well that's your first mistake.  A friend told me she wanted to become a psychotherapist - how hard is that?  Hang a shingle!  A lot of not-that-smart people seem to do it...  Let me be the first to tell you, it's not easy.  So if you're looking for easy, you can stop here. As I type this I'm juggling more than 40 people on my caseload, their LIVES in the balance. Just let that sink in. I used to work at iVillage, a startup for women in the heyday of the Internet boom around 1999-2001.  Now that was easy. They would call me in the middle of the night to fix a typo!  Now I get calls on Yom Kippur; people wanting to throw themselves into a pond. People are suffering - no doubt about that.  To become a Licensed Clinical Social Worker you have to put in YEARS of training and practice and continuing education, all at your own expense, and then you can get paid less than a secretary to manage it, with no benefits.  Until the pandemic we were literally the lowest (wo)man on the totem pole of meaningful jobs that you're supposed to be thrilled just to do.  In those years of school and work, you must be client-facing for thousands of hours, under direct supervision.  You must study not only psychopathology, but practice issues, community issues and global issues.  You must write papers, a thesis, that asks you to engage in not only measurable and evidence-based research but also keep the balls in the air, control your personal transference and dig deep inside for insight into your own reactions. No problem!  Again, if you still want to become a therapist, keep reading. I love what I do and I'm called to it.  However, I do not wish to do it all day and night. A typical intake session gathers and identifies relevant background information and present-day stressors and supports. People ask, if I had a prior therapist, how can I start all over?  In my opinion your story will emerge regardless of how much or little you tell me. I will ascertain the patterns in whatever you choose to start with.  Then comes the meat and potatoes - why do you feel the way you do, and what can we do about it?  Benefits of medicines and therapies can offer a reasonably quick recovery for some.  Harder problems require longer, slower efforts. Some people ask - please give me a diagnosis, I need a diagnosis.  Why?  Why do you? Am I BPD they ask, without even knowing what that means?  Or ADHD?  Or Bi-polar? Thirty years ago that wasn't important to me at all.  I thought I knew better.  Then I finally noticed there are indeed symptoms that match up quite well - this could be helpful.  Now I'm back to not caring - diagnosis is too reductionist.  Holistic is my path now.  OCD is not the same as cleaning the kitchen.  And a mood disorder is not the same as having a bad mood.  People get caught up without examining the distinctions.  And yes, if you drink too much coffee you will feel more anxious. In one session I hear a lot of self-blame, guilt, and loss of time and dates of things.  That tells me we might be dealing with PTSD.  In the next session I hear a lot of black and white, all or nothing thinking, a typical hallmark of young adults.  That tells me to introduce CBT, where we modify the thinker's thoughts, make them more equanimous, (In the Buddhist tradition, the term “equanimity” (upeksha in Sanskrit, upekkha in Pali) is a complex construct that has been given multiple definitions along the development of Buddhist thought. At its heart is the word for 'eye' and 'see', with a prefix suggesting 'gazing upon' or observing without interference).  I explain the concepts as I go.  This could make the recipient think that I don't have an agenda, or I'm not writing things down? But rest assured I do!  One of the things I do best is an initial assessment.  I'm good at it because for YEARS I've been practicing and studying the difference between normal teen behavior and alarming teen behavior.  I guess you could even say I'm an expert at the age of 60 yrs. In the next session I hear and see a lot of tension, stress and loss.  I'm thinking sleeplessness, self-care and grief.  Anxiety. Failure to launch.  Languishing, isolation and fear.  This is the pandemic now talking.  Did you have this before?  What were the antecedents, even though there may NOT be a one-to-one correlate to what happened before.  So keeping an even cadence, co-regulating with my client, whist my dog is barking and the doorbell is ringing and kids are arriving home from after-school activities, no matter,  I am with my client, in the present moment, making judgment calls.  I realize I need to introduce DBT in the next session.  I record a process note, do the billing, get a glass of water and lean into the next appointment.  This repeats about 10 times a day. Then a patient wants paperwork for FMLA because her dog died.  I do it without charging for my time. Did I forget anything?  Oh yeah.  I have to check in with the parents, write and email, and organize my schedule.  By the time it's 8pm I'm toast.  Since Game of Thrones ended I have no escape.  The days drone on.  I love my work but I have no benefits.  No work, no pay.  Too much work, too bad.  No health insurance - so be it.  We say we're in a mental health crisis.  No one can seem to find an affordable psychiatrist.  I have to go to my yoga class now.  The system cannot hold. Oh, and I need to order a workbook on OCD for my next patient, while I practice my own EFT (tapping) technique.  The weekend arrives and I am completely shot.  I wonder why?

Something is off and it's not just "languishing." My clients are tired, fatigued, burnt-out and incredibly lonely.  You wouldn't think it's so bad in the Big Apple but isolation lies in plain sight.  Stuck, confused and cynical about the future are the precursors to more serious immobility. I keep asking myself, where is the middle path? If a client is terrified to go out, and she instead stays in to the point of not eating or sleeping or changing clothes, suddenly a cascade of failures come before her.  And she's only 25!  She loves her family, but it's time to get out already!  So what she grew up under the shadow of an alcoholic parent.  She has a little potential to spare but nowhere to go. In the Big Apple you're either in-sync or you're not.  There are not too many slices of the pie without grabbing.  If you're catatonic, we have some great city-run hospitals that evaluate you, medicate you and then spit you back out.  If you're energetic, you can fly until you crash.  Life is a series of ups and downs.  Look into your Vagus Nerve.  Then roll the dice and see which i-Ching is yours.  Because my friends, luck is mostly all we have; and a sliver of chocolate. My clients don't want to go to the hospital.  They know what it is to get a bill for $250K because your insurance messed up again.  I know too. So what I think we need is bring back the halfway house.  Have a sanctuary for people to reclaim their worth and dignity. Have a haven for teens who can't sleep at home or need a hot meal.  Drop-in places that are warm and non-judgmental.  I'd love to be able to say, hey Susy, I know you're suffering and in pain.  It will pass.  However in the meanwhile I know a place for you to rest.  They will get you whatever you need, like some American Jews did when millions of their cousins were getting vaporized in Europe.  They got them papers and blankets and sponsors and furniture.  Where is our humanity these days?  Why are Putin and Trump at war with unsuspecting innocents?  Don't let yourself lean into authoritarianism.  We need each other more now than ever. We need resources to engage therapists in the middle path.  So we can take a day off and not lose benefits, so we can fix what we didn't break, so we can lend a hand, a meal, a ride, or a daily practice to our clients; so if it's evidence-based it doesn't have to cost an arm and a leg.  Free safe-havens for marginalized people to think, pray, love or heal. Someone to take you to your booster shot.  So young adults need not live in fear of failure. Oh blame the Internet they say.  Blame social media. Those are the symptoms not the causes.  We need more big picture people.  Those with a vision to treat patients in their homes, to bolster communities, connection and so forth. My community does this so well.  Every single day there is something for old and young.  But so many people I deal with do not have a middle path.  They have riches and hospitals, or nothing and no one.  Intensive Outpatient Programs have to expand with a single payer. Enough of holding people hostage to their jobs for health insurance.  Real freedom for students to study in peace without the dread of a bill from the ER. My friends from Sweden are not troubled by these matters.  Imagine the actual joy for our future leaders if they didn't drown in debt, loans, taxes and taking care of the elderly.  The cost of childcare.  We are hostages to capitalism now.  Just a step away from robots.

I dreaded the first face-to-face family therapy session since covid. I had pimples on my chin from masking and I didn't care to put on make-up, barely doing that in the before times. I had studied family therapy exhaustively in my 20s, fruitlessly trying to figure something out about my own family that never materialized. Therapist heal thyself. Now I faced the angry 15 year old girl with the goth look and a small, knowing smile.  No screen between us.  No buffer.  I decided I would show her I was HER therapist even as her family pushed back. There was a dialectic in this family's presentation. The parents were in denial about how severe their daughter's self doubt appeared. I had nailed it quickly, because I read and reread her discharge papers late into the night. It involved a meltdown on the first day of camp. They chalked it up to teen angst. They said their hometown was too stressful and they would move 500 miles away to change it up. Tomorrow.  Telling the kids with me there was a manipulation.  I had to stay on my toes.  We do not do the heavy lifting for our clients.  We simply help them navigate.  My skills turned to process: how do you feel? What do you feel and when do you feel it?  Again the daughter registered the fear for the whole family by biting her lips and scowling. The mother seemed cold; said she didn't like therapy. I instantly disliked her and saw her daughter's black eye make-up and wondered why she was so dark and stormy.  I saw the mother's constricted thinking on her face when she declared, "I had bad therapy in the past," and looked away, not toward, her child. Sensing dark secrets I waited for them to make their agenda clearer, but gently guided them back and back to their daughter who defiantly stated: " I can't do things," while her sister smirked. Attractive all. The parents naively thinking their child was in a stage. But the fixedness of her all-or-nothing was exhausting me. Is there no possibility that things could improve because you're moving to the country on a whim? How? Why? The father was bonded w me as soon as he proclaimed he had read "The Family Crucible," a primer on family therapy.  He was on my team.  The rest of them not so much. What do you want from your new life I said to the identified patient. How do you see yourself. How can we help you. I just want space, she said. This had been going on for years. The child didn't have anxiety, I thought, well yes agoraphobia - but it was the depression that left her stuck as if frozen in some 4th grade irrevocable choice that ended in bullying. There needs to be a bridge between mother and daughter.  How did I know? Doesn't matter.  What I knew was to ask about the process. How do you feel now, talking it out?  Could you ask your mom for what you need from her? And here began the real work. Tears. At the end we sat in silence. Good effort I said. And then I turned to the fragile, depressed girl, "I look forward to being your therapist." **Addendum: a week later I got my dear John letter. Thank you for your help as we move forward - in the new area we will be seeking in person therapy... Best of luck I say and invite the next family in... ***There was no further communication between myself and her future therapist or family therapist or psychiatrist.

PHOTO CREDIT @Rosalind Banks; Art By Rosalind @Facebook Previously published: https://centerforhealthjournalism.org/2022/06/12/college-students-are-struggling-are-schools-doing-enough-help I just returned from a law school graduation at the shockingly beautiful Cornell campus. Once known as a pressure cooker, where six students committed suicide in the 2009-2010 academic year, Cornell looks like it is working to prevent more tragedy. Bright, inviting signs for mental health help and non-judgmental support are pasted on bathroom stalls and along the walkways. As COVID turns the world into a place of greater loss and fear, colleges are facing a mental health crisis. In a February 2021 survey by the American Council on Education, 73% of college presidents identified student mental health as a pressing issue on campus — in many cases, the most pressing issue. Presidents of two-year and public four-year colleges were more likely than their private-school counterparts to voice strong concerns about the psychological and emotional wellbeing of students. Troubling as the data is, it comes as no surprise to mental health experts familiar with campus life today. “Students are arriving to college campuses with increasingly complex mental health, substance use, financial, and other challenges which may interfere with their academic success and quality of life,” said Dr. Doris Cimini, a psychologist and director of the Center for Behavioral Health Promotion and Applied Research at the State University of New York at Albany School of Education. It’s also not surprising to therapists like me who treat teens and young adults in private practice, or to parents like me who have kids in college or recent graduates. With nearly 20 million young people attending colleges and universities nationwide, these institutions are “important potential ‘safety nets’ to protect young adult mental health,” according a 2021 report by the National Academy of Medicine. Like Cornell, many schools are trying. But efforts are inconsistent. One of my children went to a public college that had “wellness” as the theme of the dorms. My other child attended a private Ivy that capped free therapy at five sessions. After that, students were on their own. Aside from the alarming mental health trends and two years of disruptions due to COVID, the obvious strain is the inherent vulnerability of this age group. Campus mental health is a critical investment at an urgent time. It’s going to take more than adding a few therapists, or, for that matter, tacking up mental health posters, to provide the support that young people need. How we got here In the years leading up to the pandemic, college students were already showing inordinate stress. One of my clients left school because of a break-up. Another wanted twice-weekly sessions because she had stopped doing her work or forgotten how to study altogether, and she would lose her scholarship if she dropped a single class. Another client told me she had a nightmare that her entire family was shot to death. Still another had a free dorm room for summer — but no food. And then there was the Georgetown law student who stepped into my office and asked me to stroke her hair to comfort her. I had never met her before! When we left young people who were already under pressure alone in their rooms for two years, what did we think would happen? About 40% of Cornell students reported feeling dysfunctional for a week or more because of depression and anxiety, according to the campus newspaper. A one-to-one intervention can be expertly timed, but how do we take care of a whole cohort? It obviously doesn’t help that anxious and depressed students at many colleges now have longer wait times for help. On the blog of Higher Ed Today, Kate Wolfe-Lyga and Marcus Hotaling outline important policy solutions. These include training all faculty and staff to become suicide-prevention gatekeepers, developing agreements with community-based agencies to supplement services provided by campus counseling centers, creating a guide that directs students to supportive resources, and including a crisis contact on student ID cards. These last two ideas are so straightforward, it’s hard to believe they’re not standard. But one of my clients called me, crying, because she couldn’t even find the campus counseling center. (“Look on a map!” I said. But she was too upset.) Best practices What some colleges do well is free, brief therapy. Much can be accomplished in 10 sessions, especially if mental health professionals are trained in short-term therapy.  The structure is good for teens and young adults, and it gets them back on track. But after those sessions, students often are left to fend for themselves. Finding therapy and psychiatry is difficult at best. And it’s often impossible for students facing financial or social barriers: young people who are undocumented, LGBTQ, food insecure or underinsured. Peer-to-peer mentorship programs and 24-hour student-run crisis hotlines, such as the model at SUNY Albany, are measurable winners. Wellness workshops can serve as a balm and give students a sense of belonging that has been all too elusive these past few years. Faculty can model self-care and wellbeing and encourage similar behaviors among students, for example, by taking lunch away from the phone and computer. Schools should also facilitate connections with professors, advisors and others who can offer support. Drop-in services are crucial. Making a serious investment in college mental health comes down to prevention, wellness, accessibility, relevant programming and community outreach. In a recent New York Times essay, Jonathan Malesic, who teaches at Southern Methodist University, reminds us of a tenet of social work: “Meet them where they are.”  My clients are beset with fears of failure, loneliness, debt, war, guns, climate change and health. By meeting them where they are, these topics and fears are put out in the open, destigmatized and given meaning. At the end of my young adult support group on Zoom every month we show our pets, because it’s that important. A beloved dog, cat or bird can reduce your blood pressure, not to mention alleviate loneliness and boredom and provide comfort. I write letters for emotional support animals all the time. Although my generation had struggles growing up too, we did not lose two years of our lives to utter dread and a flatline of boredom and social isolation. But our systems of delivery are slow. More money, time, attention and openness can create the space for more therapists to meet the skyrocketing demand. Where is government leadership on such things? At Cornell Law School graduation, the sun was shining and the students seemed hopeful. Their speaker said, “Don’t be afraid to ask the hard questions.”

A Memoir in 5 Parts LOSS: I was born in New York, New York. NYC. The Big Apple. Nothing too dramatic happened. I attended Rivervale, NJ Elementary School until first grade. I was a likable kid. I lived on a cul-de-sac called 603 Dale Court and paraded in the rain with my neighbor Mary-Beth, singing Christmas Carols haplessly along. The next home was Scarsdale, NY. Nothing was wrong there either, but there was a succession of failed dogs. When my parents started having problems I was busy with my cousins and my friends, skiing, going to Florida once, not really noticing that my friends were all wildly enriched. Nevertheless I was popular, even with braces and glasses, because I was a people pleaser, athletic and smart enough. Not top-of-the-class smart but with reasonable effort, could hang around the top quarter. In the days before phones we lived idyllic lives. Every one of my classmates remembers playing after school and coming home for dinner when dusk covered us.  I didn’t know that my father was a bi-polar narcissist either.  And for as long as I didn’t know it, I was happy.  Whether restricting food for a minute or a little anxious or sad, it had little impact. Everywhere I turned being tall and athletic buoyed me. My father and his father were known for their wit [Grandpa Sy was some kind of bridge master]. I enjoyed their easy banter and clever expressions, like one of the guys, throwing a football and learning different plays by the time I was 10.  We went to Knicks and Giants games often.  My dad being in the book business was a strange thing - no one quite understood it.  It meant that for my friends’ bat mitzvahs I embarrassingly had to give them glossy storybooks that now would be considered like fine art.  At camp I won an award: all around camper.  40 years later my own daughter would win “best all around kid” at her HS, one of the proudest moments of my life, which also includes my oldest getting into an Ivy League school. FEAR: At college I reflected on my parents’ divorce from 1976 when I was a mere 15.  My sister says, “you never got over it.”  That made me defensive.  As a therapist shouldn’t I at least have gotten over it?  I think I finally understand that there is no getting over it, as the loss of the most important person in my life was a trauma.  I fell into the trap so many of us do: thinking I could ruminate my way out of it. Turns out that doesn't work. That was another thing I never realized or named, so clueless was I to my own grief.  I continued to do well in college, even meeting Bernard Malamud the incredible Jewish novelist, and Bill (William) Kennedy, a uniquely talented writer of the “Albany” books.  I met John Glenn, the astronaut and Bessel van der Kolk, the leading expert on Trauma. GROWTH: Graduating early meant leaving my boyfriend which was a big fat mistake.  One of several I would make in the following decade.  I never had a mental breakdown, but I sure did self-destruct, picking the wrong guys at every turn.  Having “daddy issues” was fine while it lasted because I was skillful in replacing him; but it soon turned into more pain and loss.  My 20s were just a cycle of relationships all doomed from the start because fear of abandonment jinxed my insecure attachments. I met my husband at 29 and was married by 30.  He was and is the very eccentric love of my life, but never easy breezy.  One didn’t have to look much farther than his immediate family to see strain, conflict and regret -- even coldness and selfishness.  When my sister in law left her husband, my husband’s brother, after 30 plus years of marriage she railed against the pathology of the family, not realizing that I had discovered all that decades ago.  Still I held on.  One thing this family did produce was fine, intelligent and gorgeous kids.  As sperm donors they were unmatched. GRASPING: My 30s brought hard work and much frustration.  His career never seemed to gain traction.  There was an up/down rhythm to it that was all too familiar with my father, who while a rising star in his industry, made deals based on hubris not rubrix.  Creative people never get business right I’ve heard.  But he peaked and then never figured out what to do as the print went digital and he was left behind.  In an industry of young women editors from Bryn Mawr and the like, he swooped in with his charm on steroids, like Willy Loman himself, selling those manuscripts, knocking down doors, succeeding but then not, always waiting for the next BIG THING.  He trained us on how to arrange books in Barnes and Nobles and Borders so the jacket would face out on “his” books.  I grew to devour books - how could I not?  But then he was gone, and the four times a year visits to LA grew tiresome, even scary, as his behavior was erratic and unpredictable.  Not often but sometimes he would rage or have a creative streak, or a low around holidays with nothing to do. HOPE: After infertility treatment I gave birth to two spectacular girls, the gifts of my life, and I sacrificed everything for them when my husband could barely work for years after back surgery.  Yes I resented it but I saw them thrive in the last 20 years.  Both went through school relatively unscathed and both are successful in many ways academically, socially and emotionally.  I know that my work is hard and I’m supposed to take breaks. As I near the age my dear, beautiful mother was when she died of ovarian cancer, I think if I died now, I did a really incredible thing.  I used my ability to learn, care and be spiritually open to not only help others, but raise my kids to be strong, resilient leaders.  I wish I could travel more, but otherwise have few regrets.  I wish I remembered more about their childhoods -- it went so fast.

Once I was waiting in a crowded city waiting room, in the paralyzing dread of my upcoming amniocentesis.  These were the days before trigger warnings.  I just sat there waiting, knowing there was a modest risk ahead and weighing how long it had taken me to conceive. Then the receptionist shouted across the room: Mary Jo Tucker, your sonogram was positive for xyz...  Every woman sat up.  The woman was about to get tragic news and now the whole waiting room knew it.  I once said to a doctor how about I start a support group in the waiting room, for all those infertility people struggling with bad news? My other pet-peeve is honey/sweetie/dear when you don't even know me or why I'm there.  If I lost ten pounds, you could call me sweetie.  Then: you put me in a windowless room, shut the door, make me wear a too small inside/out gown and freeze while hours go by.  Or the endless hedging, like when my mother was dying, and the doctor said, "Everything's gonna be alright." It wasn't.  Or when my husband almost died after surgery and I had to run through the hospital to gather his team of doctors myself.  Another time the nurse left and just shook her head while looking at the screen. Are they doing this just to women?  "Calm down and you'll get pregnant 1,2,3."  Or I feel pain, bloat and headaches, weak, tired, anxious.  OK you're likely drug-seeking, or you're lazy or just plain stupid.  How many times have you been dismissed for something very real indeed.  (A year later, it all pointed to thyroid). Some doctors will prescribe an antidepressant, others not.  So you're down to a toss-up. Get immediate help from a trained, caring professional, or move to the back of the fragmented line. There's no one-stop shopping in medicine.  Urgent care might have been a fine idea before.  Then it lost its allure.  Long lines and randomized chaos during Covid took over that venture. Nurses of course are a whole different breed.  Some of the best people I've ever met in my life are nurses.  People who are literally the salt of the earth.  They have helped me, my family and my clients in countless small and big ways.  But in the pandemic they suffered terrible loss/sadness/grief/burnout.  Where are they now?  For mental health nurses can be life savers.  Not to discredit some fine, outstanding doctors.  But could we re-think the benefits and compensations for people who do this work day in and day out? More incentives to come out of college debt free for nurses and social workers so we can do the work we were called to do without the crushing burden of loans? Doctors are leaving by the droves.  According to JAMA, one in five are leaving their practices. Covid burnout is cited as the number one reason.  They said, "Another national health care worker survey, the Coping With COVID study, found that burnout approached 50% in 2020 among 9266 physicians across medical disciplines. Last year’s survey results, which haven’t been published yet, are more dire still, according to study coauthor Mark Linzer, MD, a professor of medicine at the University of Minnesota whose research focuses on burnout. His takeaway: burnout has increased considerably as the pandemic has dragged on." Our culture is shifting in any number of ways away from care toward robotic scenes from dystopian movies.  Greed and violence and guns and teen suicide are looming: history repeats.  Why don't we do something of substance.  Now.

By now we've discussed pandemic fatigue, languishing, anxiety, lack of services, suicide rates, social media, FOMO, triggers, fake news, school shootings, a former narcissistic, toxic, grandiose and insensitive leader (Trump), self-harm and trauma and more with our kids. By now things should go back to normal. Yet what is this new worry creeping into our consciousness?  I like to monitor new words I hear in therapy: intersectionality, amplify, conflate, weaponize, - fighting words. I'm also hearing this: "what's the point?" Or, the perennial, "how can I go to the best college?" These two extremes are not that far apart. One kid realizes she can check out and nobody will notice or care; another says the only way out is to torture herself with work and worry.  Neither is helpful or productive. Depression looks different in young adults in some ways.  So does mania.  Going to extremes and black and white thinking is a hallmark of the adolescent brain.  How do young adults find balance in a world increasingly in chaos?  How can I teach DBT or self-regulation when before my head hit the pillow I asked myself for the first time in my life, "what if there's nuclear war?" We start with the breathe says my yoga teacher.  I guess the fulcrum of yoga and psychotherapy, or eastern thought and psychotherapy are a potentially liberating place from which to launch, when all else fails.  According to Mark Epstein, “When we stop distancing ourselves from the pain in the world, our own or others’, we create the possibility of a new experience, one that often surprises because of how much joy, connection, or relief it yields. Destruction may continue, but humanity shines through.”― Mark Epstein, The Trauma of Everyday Life If I had a dollar for every time I asked a teen to stop avoiding and start living...  fear cannot help you treat anxiety.  Only exposure can.  If we face the thing we fear, and we don't get struck by a lightning bolt, we can continue on our journey.  The only way around is through.  Or as Pema Chodron said, “The only reason we don't open our hearts and minds to other people is that they trigger confusion in us that we don't feel brave enough or sane enough to deal with. To the degree that we look clearly and compassionately at ourselves, we feel confident and fearless about looking into someone else's eyes. ”― Pema Chodron Lisa DaMour, one of my favorite authors on teens and therapy, has discussed the enormous pressure on this generation in her book "Under Pressure."  One of the things she emphasizes is that we have to teach kids to TOLERATE discomfort, “Unfortunately, anxiety, like stress, has gotten a bad rap. Somewhere along the line we got the idea that emotional discomfort is always a bad thing.”― Lisa Damour, Under Pressure: Confronting the Epidemic of Stress and Anxiety in Girls Try telling that to a 16 year old who just had a break-up and refuses to go to school.  Or the almost 17 year old that her parents' divorce is not going to cause her grief and upset as long as they conduct themselves with respect for the family.  When asked how her parents were behaving, one pre-teen told me, "They lead 'common lives.'"  I thought that was funny -- but yes, isn't that the goal?!  Some of these parents are acting like teenagers themselves as they frantically run from partner to partner and forget to make dinner.  All the kid wants is the car keys and the answer key.  To which the answer is usually a hard NO.  Or what if that teen's behavior suddenly becomes erratic to the point of misjudgment on everyone's part -- now that's when you might call the therapist. But for all this to work, the precondition is openness. When I rattle off 25 things the person can do to self-regulate and they do none of them during the week, what do you think changes?  Nothing.  Because they didn't change anything!  Resistance, anger, judgment and shame are all barriers to care.  Take a step back and slow down the therapy.  Make time to breathe and be still.  Then maybe you'll have a fighting chance at change.  But with no effort or over-effort, the body tenses; the work gets stuck; the future is frozen.  As the great Irvin Yalom said, “Despair is the price one pays for self-awareness. Look deeply into life, and you'll always find despair.”― Irvin D. Yalom, When Nietzsche Wept Despair is not the end -- it's the beginning of being seen, heard, understood.  Let's allow it some space.  Get ready.  Go.

Let’s get rid of it.  The hook-up culture. I don’t know when it started. But let’s stop it. I’m guessing it began as a feminist thing. We want casual sex too! We don’t care! Our Bodies, Our Selves. But we do care. In the last 15 years of my practice never once have I heard a young girl tell me that she liked being dumped the morning after.  As I was watching these confident olympian girls and women, first coming forward about that sickening doctor and then scoring gold medals in Korea, I though why must we put up with this at all?  Yes there has been a #metoo movement and a #metoo backlash including the former President Trump himself, but the real change has to come from our behavior. Say no to the hook-up (if you want to)! As my favorite therapist Lisa Damour stated in the NY Times a few months ago, don’t allow nudes. Make it wrong for a boy to even ask. Make the burden on him. Make them accountable. Make it REALLY BAD for men to ghost women. My daughter is at a prestigious private college. She showed me an article that said 1 in 4 girls get sexually assaulted by the time they graduate. Really? Is that where my money is going? How can colleges sell themselves with that kind of mindset? According to Damour, An analysis of nearly 500 accounts from 12- to 18-year-old girls about their negative experiences with sexting found that over two-thirds had been asked for explicit images. According to the Washington Post, "Of students who reported hooking up, 41 percent used words such as “regretful,” “empty,” “miserable,” “disgusted,” “ashamed,” “duped” and even “abused” to describe the experience." I am seeing more and more young girls in therapy who have been sexually assaulted. I started thinking deeply about it.  And don’t you know I started to remember whole swaths of experiences that I myself had blocked out.  When we block out experiences we bring on states that young people nowadays call “numbing” or “emptiness.” This cutting off of experience or disassociation leads to serious problems down the road such as depression, alcoholism, avoidance and social anxiety.  I sat with my discomfort for a while. Then I read an excellent book called “Stolen Tomorrows” by Steven Levenkron.  What I discovered is that while my clients were complaining about hookups, hangovers, sexting and texting, what they were really reporting is that they had been abused in one form or another.  I found I was trivializing it by instead of saying, “Can you tell me more about that,” I was rushing past it, as if I wanted to push the trauma away.  I mean who really wants to talk about a one-night stand that ended badly?  The therapeutic task is to stay with the pain until it is healed sufficiently to move on; not breeze by it as if it never happened, just like the bumble who didn’t call back. This is why the mind/body connection is so profound; releasing trauma is a subtle, emotional and physical task (See: Bessel Van Der Kolk). How can we work through this culture shift: It’s never a good idea to have sex when you’re wasted. It’s lonely to have sex with someone you barely know. Sex with a stranger can lead to feelings of shame and regret. It’s OK to be alone. It encourages boys to behave badly. It gives you an emotional hangover. Starting out as friends is OK. Frat boys need manners: binge drinking is a disease. Consent is not a choice. Being rude, unreliable, fake and distant is thoughtless. Let’s make the next generation better, not more afraid.  Change can come incrementally and powerfully with our collective will and wisdom. It has to. Moss, D. (2019). Hook-Ups, Hangovers and Hopelessness: How not to Waste your College Years. Psych Central. Retrieved on May 11, 2020, from https://blogs.psychcentral.com/sext-text/2019/03/hook-ups-hangovers-and-hopelessness-how-not-to-waste-your-college-years/

As we enter this third year of pandemic madness (which I thought was going to be over in two weeks), I managed to work constantly while staying in my little bubble of neighbors, friends and family, keeping my kids safe, getting one a vaccine in Plattsburg, NY, convincing my husband it would not cause him a blood clot.  It was an effort worthy enough for any family, still I stayed close to home, went to the usual spots and even planned a tiny vacation. At the vacation we learned that one of us had had a positive exposure.  From there we literally devolved into tiny mini head spins: when exposed, where exposed, how exposed and on and on.  OK get a test - you say.  Not so easy except I happened to have ordered a couple of tests online.  So she tested negative.  All was well after a day's worth of bickering.  I realized now that things went so much deeper in terms of our collective losses.  The empty zoom funerals, my clients' loss of work and connections.  The kids trapped in their rooms.  But this was different.  No one was going to die; we hopefully took care of that.  But we suddenly experienced the swirling anxiety of travel, uncertainty and turning on each other out of sheer draining frustration.  It didn't help that it was raining. I think this episode, which really only consisted of a lot of yelling about tests, taught me much more about the universal experiences of disenfranchised grief.  It taught me that each and every action has an equal and opposite reaction.  I learned that in spite of every precaution, my client who never went out and got covid in a cab was devastated, right before her wedding.  The people who got cats and dogs were happily walking around my quiet suburban idyll while others were languishing in hospital beds, quarantine, solo apartments, etc.  Movies without masked people seemed quaint.  I have to dig deeper I thought.  Now with my clients I'm not going to just roll my eyes about politics and safety and boosters and other pandemics of the past and working together.  I'm going to ask them, "How did this really effect you?"  "How is the ongoing strain on your life?"  "What can you change to start to feel more in control?"  "What do you miss about going out?" The experience is a package deal now: survival of the fittest, also the most flexible, and the most willing to accept the here and now. Instead of "Peace be with you" or "Namaste" or "See ya" I will say truly "Be Well in body/mind and spirit."

PHOTO CREDIT: Jennie Carr My phone rings three times a day with the same message: my teenage (daughter) needs someone to talk to.  I try to be my usual calm self.  I ask certain intake questions.  I say there may be a wait list.  For the first time in my social work career there is a demand that no one saw coming.  For the first time we can perhaps get more business, more money, help more people, be important even.  It's quite seductive in a field where starting salaries can be no higher than 35,000$ per year at the height of your powers.  We are used to having no pensions, no respect, shoved aside by doctors and nurses, even psychologists.  We are those people who deal with things like broken homes, getting medicaid, working out a bus route.  I once had three interviews and then no callback for a job that was 3 decades below my level.  If you work in a clinic, you get bean counters checking your every move while real people suffer with real problems, waiting, waiting for help.  In many cases, whether it's the inner city or the suburbs they wait. Now comes covid.  For a while I rode that wave by booking more and more appointments. It became very alluring to be wanted, needed and in demand.  But it soon became much too much.  We therapists talk a good game about self-care but we rarely practice it so well.  We have to practice what we preach.  So now how to get off the roller coaster. Cutting back and taking higher paying clients is one way, creating even more demand. But once you're in the insurance racket everything changes.  You are forced to accept drastically lower rates and compelled to do endless paperwork.  Most in my area have opted out of all that.  What does that do to the people who have really emergent needs? My colleagues are saying some very very simple things.  It comes down to access and money.  None of this is new.  Medicaid and Medicare do not typically include other types of licensed mental health professionals.  In addition the regular insurance company's jobs are to limit care.  It's that plain.  When the incentive is the bottom line, and not care, everyone suffers.  Healthcare becomes a privilege, not a right.  Therefore it's the neediest who get the least help.  I work with solidly middle class families, those working for their benefits and wanting to use them.  According to another therapist, Jennifer Rowe, LCSW, "prior authorizations, lack of reimbursement, constant resubmissions to obtain payment for service..." created a barrier. Yet most of my peers are "out of network" because they themselves can't live on the fees that the network pays us. We in private practice have no benefits.  This is why our rates may seem high.  Rates for therapy around the NY area range anywhere from $60 to $350 per session.  If you happen to need a prescription along with that, psychiatric evals can start as high as $850 for the initial evaluation. Access and money. Now every teenage girl needs someone to talk to.  That's great news!  They were locked up for 18 months of their incredibly stressful lives, at the exact moment their brains were seeking comfort from their friends and their bodies were going through monumental changes.  The isolation, languishing and depression would be putting it mildly.  These kids were flattened.  Lifeless, listless, empty, you name it.  I'm surprised there wasn't a new diagnosis called childhood burnout.  My colleague, Gayle Skovron, LCSW of Nyack, NY said, "We ignored and stigmatized mental health for too long. This is the fall out of torn families, lack of community and greed."  Another Clinic Director, Max Benezra, EdM, MA, LMHC, from Sound Shore Counseling in NY reported, "We experienced such an increase in referrals during the pandemic, especially with teens, that we hired more therapists and still did not have enough therapists to meet the demand. Additionally, the tiresome nature of insurance reimbursement, particularly when telehealth was first being instituted during the pandemic, made it all the more difficult to provide our patients with the support they sorely needed." Lastly, and this is an extremely overlooked dilemma, according to NY therapist Jessica Hazard, LCSW, "Some difficulties I have been experiencing in my private practice is that parents can clearly see their children are suffering but want them to "snap out of it" and "behave like they used to." It is hard for them to see their kids having a tough time and so they want the healing and behavior change to happen rapidly. Having to tolerate that it will take time is proving difficult for them. I have a patient who has historically been a very good student that is currently failing two classes. They have never even come close to failing something so the parents are demeaning her and putting tons of pressure to perform as she once did. Some of the work is with the parents realizing the pressure is adding to their struggles and making it more difficult to do the things they once did. And it also feels challenging to me as a clinician because if parents are not liking the "results" they can get rid of me prematurely even if both the teen and I feel we are doing good work together. The rest is history.  No policy changes were made besides a brief covering of copays and of course telehealth.  Bold for the short term but what if you still had a high deductible and your teen girl was putting gashes in her arm out of boredom?  I was contacted by the parent of triplets -- they all needed therapy.  There was a time this would have been a perfect gig for me.  I said no.  The mother was desperate.  I said I would help her.  But I can no more help them than help myself.  I let my hair go grey.  My wise therapist told me, "having more patients does not make you a better therapist." "The report cited significant increases in self-reports of depression and anxiety along with more emergency room visits for mental health issues. In the United States, emergency room visits for suicide attempts rose 51 percent for adolescent girls in early 2021 as compared to the same period in 2019. The figure rose 4 percent for boys." --https://www.nytimes.com/2021/12/07/science/pandemic-adolescents-depression-anxiety.html Where is the policy change here among all the statements?  We wait.

Three weeks ago a former patient contacted me because she had suddenly recalled an episode from her past, so long ago it was nearly forgotten.  She wanted to sort it out.  We had already established trust and safety in our former treatment.  OK I said, let's go slowly. Making sure she was calm and regulated we chatted for a moment about our annoying dogs.  The she told her trauma story. While walking home from school she was attacked, touched and humiliated by a group of school mates in her home country of Lithuania.  As a young girl, and the youngest of her large family, she was often ignored, although she was extremely bright.  She was also the tallest girl in her class, making her stand out.  After this event where she was thankfully unharmed she internalized the shame that many of us have after a traumatic experience.  She stored it in her body and it petrified until frozen, cut off, exiled.  All of this language I use here is from one man's work, of course, Bessel Van Der Kolk, The Body Keeps the Score.  Why this book is now on the bestseller list is your guess.  The pandemic brought it home.  No amount of talk therapy can unfreeze you.  In fact, we have learned it can re-traumatize you, the antithesis of what we want to achieve.  What should I do I thought? As we were running out of time, and it was by phone, I asked her to reflect on the experience of telling it.  She said she felt much relieved.  I encouraged her to meet with me again when we had more time.  Several weeks later she said she was ready to talk again.  We set up a phone session during which we would both walk our dogs. In the following session she spoke of another, similar experience, and how again she felt ashamed.  I asked her to take some nice slow breathes.  Why do I think it's my fault she asked.  I explained that because she was powerless then, she blamed herself for her inaction.  I also explained how trauma works and how she may have shut down as her only defense against real danger.  I explained that she protected herself and that was something to be grateful for.  As we spoke I validated her story each step of the way.  I waited patiently for her to continue.  I told her she was safe now.  That no one could injure her in that way now.  That she had learned to slowly trust those closest to her.  She realized that her mother may not have been able to empathize because she was simply too tied up with mothering to be available emotionally.  The client gained wisdom, perspective and stability by reaching out and reaching in. How do you feel now?  She said thank you so much for allowing me to feel safe again.  I said I don't have superpowers but I do understand the process.  She asked if she needed more therapy.  I said you decide.  Whenever and however you're ready to continue, let me know. What an honor to hand the power back.  No longer a victim, she happily told of her job pursuits and her marriage.  We were both entirely satisfied.  That is the work.