April is National Counseling Awareness Month, according to the Greater Baltimore Counseling Center. It is a time to not only honor the professionals in the counseling field but to also understand the importance of counseling and the vast benefits it can bring.
Counseling has made a huge difference in my life — thanks to my guidance counselor at Monta Vista High School (MVHS), Clay Stiver. Whether it be helping me with anything academic-related, with future career aspirations or even with social-emotional aspects, it is safe to say that a counselor’s presence while I navigate the strenuous years of high school has positively impacted my life. I truly appreciate being fortunate enough to have someone so vested in not only my academic success but my general well-being as well.
That being said, this month is a perfect opportunity to delve deeper into the often-overlooked profession of counseling and just how remarkable it can be.
Merriam Webster defines counseling as: “professional guidance of the individual by utilizing
psychological methods especially in collecting case history data, using various techniques of the personal interview, and testing interests and aptitudes.”
MVHS Guidance Counselor Clay Stiver expands on this definition of counseling using his own experiences as a counselor.
“I look at counseling as a supportive collaboration towards a goal of some kind — [whether it be] academic counseling, college counseling or social-emotional counseling,” Stiver said. “The goal can be dealing with a crisis of some sort of working on long term goals — academically or social-emotionally.”
Stiver also shares his joys of counseling — and how they shape his profession.
“I really like helping people,” Stiver said. “And high school is such a big transitional time; I wanted to be a support for students — a conduit to success or social-emotional growth. It is rewarding.”
Along with being a counselor come responsibilities pertaining to the job; these responsibilities can vary depending on the specific type of counselor — since there are many. In general, Betterteam states that counselors are responsible for hearing what their patients may have to say, creating treatment plans for individual patients and developing strategies for coping.
Stiver describes his specific profession as a guidance counselor for MVHS — someone who handles three main domains when counseling students: the academic and college domain, the career domain and the social-emotional domain. He also outlines the responsibilities of his specialized counseling profession.
“[On] a surface level, my responsibilities cover the three domains of my profession,” Stiver said. “When it comes to academics, it is to make sure my students are on track to graduate [MVHS] and deliver [the MVHS] yearly guidance curriculum. But it is also to give support to parents, students or teachers — to be here for crisis situations and help find resources.”
The Benefits of Counseling
There is often a stigma surrounding counseling — that it exposes your weaknesses and is something that you should not engage in. Yet this is not true.
As Brené Brown — a research professor at the University of Houston — says in her novelDaring Greatly: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent, and Lead, “Vulnerability sounds like truth and feels like courage. Truth and courage aren’t always comfortable but they are never a weakness.”
Brown articulates the importance of sharing vulnerability rather than being scared of the act. Counseling is a way to do so — to help out instead of exposing weakness. Stiver shares the same sentiment; regardless of what one may be going through, counseling has the potential to offer some help.
“[Counseling] can provide new perspectives — a neutral third party,” Stiver said. “It entails having an advocate for, in my case, students who do not feel as though they have a voice. [Counseling] provides a listening ear as support.”
Clearly, counseling can have innumerable merits — and one can always reach out to get help. In fact, Stiver shares a few ways to do so.
“If I was a student, I would do one of three things — or all three,” Stiver said. “The first is to see one of the guidance counselors [at school] — a brief chat can help a lot, whether it be with resources or social-emotional support. [Another option] would be to go to my doctor and talk to them about what services they may know of or provide themselves. [The third option] is going to my parents — if appropriate given the situation — for help.”
Unfortunately, guidance counselors — although extremely valuable — are not equally accessible to some students across the United States of America, particularly low-income students. In fact, more than one-fifth of public high schools across the nation do not have access to even one guidance counselor, as reported by the Education Department’s Office for Civil Rights in 2016. Though many protests have occurred to persuade districts to offer more resources — such as guidance counselors — for schools, progress is still quite slow.
“We can do better,” Stiver said. “We, as a school, say that we prioritize mental health — it is time to show it.”
Given that this month is National Counseling Awareness Month, it is important, more now than ever, to share the benefits of counseling; every student in the nation should have access to someone who can help them with their school careers as Stiver helped me with mine. Every student in the nation deserves someone to help them live up to their absolute fullest potential — someone who can give them the academic, career and social-emotion support they need.
My name is Sania, and today I have with me Dr. Vidhya Krishnan, who is a child psychiatrist. We will be talking about the treatment of depression using biopsychosocial interventions.
Before we do that however, would you like to introduce yourself, Dr. Krishnan?
Dr. Krishnan (DK): Sure. Thank you, Sania, for having me today. As you already mentioned, I’m Dr. Krishnan and I’m a child and adolescent psychiatrist. For my day job, I work at the Children’s Health Council in Palo Alto where I’m the head of adolescent mental health services.
What are the different ways you treat depression?
DK: So depression obviously is a mental health condition. It is the language we use for the condition called major depressive disorder, and a few other depressive conditions. Whenever we try to address a mental health condition, we try to come at it from very, very different directions.
So, we try to address the biology of the condition which is what is happening from a chemical, neurocircuitry kind of a standpoint, and psychological, which is the way the brain thinks and processes information, and then we come at it from a social standpoint, but I want to include that to say both social and environmental.
The reason I break it up into these three parts is because [the biological umbrella includes interventions like medication]. The psychological part would be therapy. The various kinds of therapies one might use includes “talk therapy,” one of the more popular kinds.
[However] there are other kinds of therapies people use to treat depression [that address] the social or the environmental factors include things that people do: what’s happening in school, and in a person’s family life, friend circle, even things we do on a daily basis, what we eat, how we sleep, the level of activity we do. So what I would like to say is overall, the treatment of depression includes a wide umbrella of things that basically touches every aspect of a person’s existence.
TF: That’s incredibly interesting to know. I knew that there was therapy and medication, but I didn’t realize that there was such a wide variety of ways that depression was treated. And so that leads me to my next question, which is,
When do you recommend a child’s depression be treated with medication in terms of their age and severity?
DK: So as far as the age goes, there is no particular cutoff. […] There’s not an age below at which we will not treat depression and there is not an age above which we will not treat depression. So I think the question, most importantly, is what presents in front of you. I think of two big categories when I bring up the idea of using medication to treat depression with my clients and their families.
One of them is the severity of the depression. If someone has what we would like to call a moderate to severe level of depression, medications automatically enter the conversation. Just because we talk about it doesn’t mean we always do it, but that definitely shows that things are sever enough that it should be talked about.
The other big factor is functional impairment, right? The way a child goes to the world, they have a family component of their life, a school component of their life, and a social component of their life. If the depression [has progressed] to a point where it’s affecting all or some of these aspects to a big degree where a child’s ability to engage with their school, which is their main job, or their family or their friends is impacted in a big way, we do consider the possibility of medications as one of the things we might want to do to help them get back on a sound footing in their life. So I would say severity and functionality are the two main criteria I use when making medication recommendations.
TF: So that’s very interesting. I didn’t realize that there is no age limit or age range in which it should be treated with medication, so thank you so much for telling us that. And I’ve also seen a lot of people with depression, that see therapists and take medication, but I never really understood how exactly the medication helps with depression.
So can you explain what medications do and why simply going to a therapist isn’t enough in some cases?
DK: For a combination of reasons! Depression, obviously, is a sum of many different factors, right? There is genetic vulnerability, on top of which, there could be medical conditions or life circumstances, which conspire with each other to basically tilt the needle towards the person’s emotional health responding through depression, sometimes in triggered situations where there are negative life situations. Either within someone’s control or not, but sometimes depression can happen for no reason at all. Due respect to why a person becomes depressed at a particular point, there always are neurochemical and neurocircuitry kinds of changes that are observable in the brain, that is easily discernible through PET scan and various other functional metrics of analysis.
Like if you took a picture of someone’s brain who’s depressed, you can see that the various cells in the brain are not talking to each other as well as the like for them to, and the various parts of the brain also, at a bigger level, are not communicating with each other as effectively or efficiently as we’d like to.
And this is obviously a very big challenge because that is a big barrier to being able to experience benefit[s of treatment]; If you think of therapy, [it] is learning new ways of teaching someone new ways for the brain to deal with the world outside of themselves, or even in the way that we talk to ourselves inside of our head as we get prepared to deal with life or life’s circumstances.
The trouble is that when you have therapy alone and the level of depression is extremely significant, these large parts of your mind are not exactly working the way they’re supposed to. Even if the right kind of therapy is available, the barrier because of this lack of appropriate communication between the various parts of the brain is [such a barrier] that therapy alone cannot [provide sufficient support]. It’s almost like asking someone to jump over a wall that’s way too tall—it’s not possible to do no matter how much coaching or training you get. Sometimes you just need that ladder*. (*Note from TF: …and that’s okay!)
Sometimes medicine, if you think about it, is that ladder that you use to be able to climb over taller walls. Someone can coach you on how to climb the ladder, how quickly you can climb it, and how easily you can get over the top. But if you think about it that’s kind of the role it does it makes these parts of the brain have the chemicals necessary in the tank to be able to be available when the right messages come in, so the message is able to go through but also the same time allows for these various parts of the brain to talk to each other a lot more efficiently. It’s almost like it greases the wheels.
TF: That makes a lot of sense, so medicine is kind of like a booster that can really help you get out of your depressive phase or kind of, you know, ease your depression. And so, the next question is,
Once one of your patients starts taking medicine for depression, how long do they need to take it to see results and when would you eventually stop or taper down on the medication?
DK: So the medications, because of what I just explained as what the medications need to do, create this tank of chemicals that needs to be there in your brain so that, you know, […] various parts of the brain are able to communicate with each other more effectively. But eventually, the job of the medicine is to help the body build its own tank of chemicals. And for these effective communication roles that you have developed, almost like information superhighways, to kind of work of their own volition without the aid of medications. What ends up happening though, is this whole process of the brain becoming self-sufficient without the need of this external booster, like you said Sania, […] it takes the brain a while to get into this new habit if you will.
So number one, for the medicine to just start working to build the original time, it can take anywhere from four to six weeks, which is a long period of time and I understand. But given how long [treatment sometimes lasts], six weeks in that scheme of things does not feel like a large amount of time. But once we have found that the medicine is helpful or effective, the treatment of what we call an episode of depression needs to usually last somewhere in the order of about nine months to a year or a year and a half.
The reason for it is it takes that long to shore up the body’s defenses to undo some of the problems that have happened because of the brain being in a depressed place because certain parts of the brain to grow it the way they’re supposed to. It’s almost the same way you think of is you know when a child’s body is malnourished, they don’t grow tall, they don’t put on weight, their body is not able to do the various age-related tasks its due. Similarly a brain that is under the influence of depression doesn’t grow the way it’s supposed to grow and doesn’t do all the tasks and activities that it’s supposed to do for that age and stage of life. So you need to have that regrowth and that catch-up happens before you’re able to get out of that episode of depression. And that takes time, which explains the nine months to a year, year and a half timeline.
One of the things I always talk about is the window of time that we are using medications to address the symptoms of depression. It’s a great period of time to kind of combine that with the therapy because as the brain is growing back, like I said developmentally catching up, right, because depression has almost been like a pause button. What is happening is therapy added in at that particular point can accelerate that process significantly. So to be able to successfully get to that year mark are nine months or a year and a half mark and be at a place of readiness to be able to stop the medicines requires the person to be able to have caught up and keep up with all the things that have happened in that particular time and so I would say three things right?
Giving the brain enough time and space to do the growing it needs and the catching up it needs to do but also modifying the various thinking changes that have happened because of depression by the combination of therapy, is what gets somebody to a place of readiness to see both results and be at a place where you’re ready to stop the medications and kind of move on from that phase of treatment.
Though one other other point it would be useful to add here is that everything that I said right now is valid when you’re looking at someone in their first episode of depression or for the first instance of treatment. But it is important to remember that not everybody responds to the first medicine or the first treatment they take.
And not everybody’s in the first episode of depression. Sometimes this is maybe the second time or the third time someone’s struggling. But in those instances, the answer is a lot more customized and it is something that one should discuss with one’s doctors because once you get into further episodes of depression or more longer duration of illness, other variables start to matter in terms of how long it takes to see results or when a person is ready to stop [treatment].
TF: Yeah, that makes a lot of sense. I like how you said that that it’s, you know, it’s not like a one-size-fits-all type of thing, right? Not all patients will respond to the same medication the same way. And I think it’s really important for people to know that just because the first one didn’t work doesn’t mean the ones after that won’t work, you know?
TF: And so my last question to you is, just to tangent off of that,
How do you deal with suicidal thoughts or tendencies of patients that have depression?
DK: So one way to think about it is, at least as far as people with depression or concern, you want to think of suicidal thoughts or suicidal tendencies as a part of the depressive profile if you will, right. For many kids and including adults, it flows from the symptoms of depression in the sense that “I don’t feel like my life was worth living, I don’t feel like I’m able to help myself or either good enough light that feels meaningful.” And many people without even consciously realizing it slipped into a phase where they start to say, “I don’t matter’ or “My life doesn’t matter.” “What’s the point anyway, I wish I was dead.” “Nobody would be sad if I died.” And sometimes this goes into a place where they start to think that, you know, “I think I’m a burden, I think I am not of value, and what does it matter if I die? Nobody will miss me.”
First things first, I always say that one should not fear asking these kinds of questions if it’s [to] a family or a member or a loved one because it’s a very common thing we see in people with depression, even if they’re not at a point where they’re going to do anything about it. This kind of negative thought pattern is actually very core to just the symptoms of depression themselves, and many of the people who are […] stuck in this thought pattern find that when the depression lifts, these thoughts also get better and go away.
So I think you want to first start by thinking of it as a part and parcel of depression, and not be fearful of asking or checking in [with loved ones] about these thoughts if a person does have them to see hey if you have them because it might be a great sense of relief for someone to share this with somebody and now somebody knows, which means somebody can help, which means somebody can point you in the right direction of what can happen next. And so that is the first thing, asking, checking in, and knowing about it is extremely important.
The other thing that is also important is there are studies out there that show that there may be a very, very small, but nonetheless, important thing where when you start treatment, whether with therapy or whether with medication, there can sometimes be a change or a worsening of these thoughts initially.
That does not mean that the treatment is not working.
Dr. Vidhya Krishnan
Sometimes what ends up happening is treatment makes a person be able to see where their life is a little bit more clearly, and what they see around them may not be something they like because of how much damage depression has done to their life and their circumstances and it can be very disheartening, to begin with. That’s exactly the point where we need to let somebody know that help is on the way, that there is light at the end of the tunnel and holding their hand.
So, instilling a sense of hope and knowing that they have people who are in their corner, people who are rooting for them (who know what they’re doing and who are able to help can preserve that sense of fullness), almost a “substituted hopefulness,” which comes from the outside until the actual treatments for the depression are able to kick in. So there is a period of vulnerability where we might know about these thoughts and feelings but we are not quite in a place where we are able to fully address them, which is when the external help a friend, a colleague or parent or relative, a doctor or a therapist can be so important and so valuable in supporting someone through that particular phase. But most times, as the depression improves, simultaneous to that we also see an improvement in these thoughts and feelings, automatically.
But if that’s not the case, and you’re not seeing those changes, therapy can play a significant role. Because sometimes these suicidal thoughts are almost a, I wouldn’t say a maladaptive coping, it’s felt like “That is the solution to my problems.” And so finding alternative solutions in conjunction with a really good therapist can replace these thoughts and feelings with other, more helpful thoughts and actually have a good chance of being able to help these thoughts and feelings.
So I think you want to think of suicidal thoughts and tendencies almost lockstep with the depression in your treatment of depression, as one of many things we try to address the same way we might try to address sleep or difficulties or appetite difficulties, and this is just one more of those things that we deal with.
TF: Yeah, that’s super helpful to know. I think it’s really nice to know that it’s not something that’s uncommon for people with depression, and it’s, you know, something that happens and it’s something that can be treated and something that can be improved with medication and with therapy. So that is an amazing thing. And thank you so much for joining us today in this interview. I learned a wealth of information, and I’m sure a lot of our listeners did too. So thank you so much.
Taarika Foundation (TF): What exactly is ADHD and how does it affect people who have it?
Leah Anderson (LA): ADHD is also known as attention deficit hyperactivity disorder and it affects the ability to concentrate and to sit still. It generally affects children and manifests itself in impulsive behaviors and being overly active. It causes people to have an inability to sit still for a long period and to focus on a task for more than a few minutes.
How can ADHD make studying and school challenging?
LA: With school, obviously you have to sit through school for 45 mins. My classes are 80 mins which is even longer to sit still and focus. It is harder to sit down and take a test or sit down and study for a long period or to focus during school.
Is there a way to teach people to cope with their ADHD so that it has little to no effect on them?
LA: For mental disorders such as ADHD I have learned that the most important thing is coping skills. Coping skills in this context mean figuring out the ways to learn that work for you. Some people with ADHD can sit for 15-20 minutes while some people with ADHD can only sit for five minutes. The biggest thing for me is to have enough breaks so that I can walk around and move, and learn how to focus myself in a way that I can learn.
What help/treatment have you received for ADHD? Has it helped?
LA: So I take medications to help with my ADHD, but unless there is an effort put in, for me to realize that I have this hindrance, the most important thing for me is to use my skills because the medication can only do so much. I have a learning specialist to help me with the things that I have issues with like essays and taking a test.
What advice would you give to the teens who have ADHD?
LA: The most important thing is getting tested, and knowing that you have this diagnosis. If you know you have this diagnosis you can go to your school and talk to them about accommodations which for me, have been very helpful in the past. Another thing is to take breaks and learn about yourself. It is not about how well your classmates learn and how your teacher teaches you, it is learning how you can best take in information and sit for longer periods of time. Talking to a psychiatrist is also helpful because they can prescribe medications to you that can help lower some of the effects of ADHD.
TF: Today, we interviewed Leah Anderson, a senior at Harker High School. We learned a lot about ADHD and how it can affect study habits and skills. We also learned how you can cope with your ADHD to form good study skills and to be mindful. Again, special thanks to Leah Anderson for helping us with this podcast. We are from the Taarika Foundation, and you are listening to Mindful, Beautiful, and Thriving. Be sure to stay safe and stay home.
Taarika Foundation (TF): Hello everyone, and welcome to Mindful. Beautiful, and Thriving. Today’s podcast is about the treatment of ADHD. With us is Doctor Leena Khanzode, a child psychiatrist in private practice in the Bay Area. She is also an adjunct clinical faculty member at Stanford University.
TF: Hi Dr. Leena! Thanks for being with us today.
What is ADHD? How common is it?
Dr. Leena Khanzode (DLK): ADHD stands for “Attention Deficit Hyperactivity Disorder.” We classify it as if somebody has ADHD predominantly inattentive type, they have symptoms that are related to low attention. ADHD predominantly hyperactive type is when people are really hyper and fidgety, they have impulse control. In general, girls have the inattentive type and boys have the hyperactive type. It is extremely common, 1 in 7 kids have ADHD. It is a neuropsychiatric condition. This can run in families, this means that you can be born with a differently wired brain which can give you ADHD. Some people tend to outgrow ADHD but some people also have to stay on meds that help them with it for the rest of their life.
Is there more than one way to treat ADHD, and if so can you tell us a few of them?
DLK: ADHD is treated in a more holistic way. There are three domains of intervention. Biological intervention is when medicine comes into play, psychological intervention when therapy comes in, and social intervention where we look at school and home. We understand that ADHD affects the child’s life everywhere, not only in school. A combination approach works best, using both medicine and working on changing habits. ADHD makes kids feel like they are the problem child.
Does the type of treatment a person gets depend on the level of ADHD that they have?
DLK: Yes, it does change with the level of severity. If someone has mild ADHD, then we would often avoid medication. If someone has severe ADHD, we use medication, aids at school, and tools that help the person to study and focus.
Which way of treating ADHD is the most effective?
DLK: A combination of Bio/Psycho Intervention. Having tutors to work with and aids in school work best and sometimes we can avoid medication. Sometimes a lot of classes can be hard for even a bright kid to support and in these instances is when we would use medicine to help the kid focus. Medicine used to combat ADHD is called stimulants. These stimulants release dopamine which helps our brain to be alert and to focus on one subject for longer. These stimulants can work from 8 to 10 hours. There are other types of medication called non-stimulants. These medicines take weeks to build up in your system but unlike stimulants, these medicines work 24/7 because they are working to combat your ADHD. Non-stimulants take time to build, but long-term they will work to help you focus. Both of these types of medications are very effective.
To treat ADHD, does the person getting the treatment have to put their own effort along with the medicine?
DLK: You need to actively try to focus. Even though medicine does a lot of work, a lot of the work comes from the motivation of the person trying to focus and trying to finish all the things that they have to do.
Can someone outgrow ADHD? How does that happen?
DLK: Yes, someone can outgrow ADHD. There was a study that was done following kids with ADHD for 10+ years and they found that ⅓ of these kids were able to outgrow ADHD.
Why is it important to treat ADHD and what would happen if someone left it untreated?
DLK: It is important to treat ADHD because kids develop anxiety as they are not doing well in school and they are constantly getting in trouble. This anxiety can lead to other mental disorders such as depression. A lot of teens are prone to abuse substances due to their lack of impulse control. Treating ADHD is important because the consequences of not treating it can be very detrimental.
TF: Today, we interviewed Leena Khanzode, A child psychiatrist, an Adjunct Clinical Faculty at Stanford. We learned a lot about the treatment of ADHD and how the person getting the treatment has to put effort into it. Again, special thanks to Leena Khanzode for helping us with this podcast. This is the Taarika Foundation, and you are listening to Mindful, Beautiful, and Thriving. Be sure to stay safe and stay home.