I walk into the exam room on a Friday afternoon to find a 16-year-old female who is coming in to see me for a sport physical. On paper, everything looks great: Her vital signs are on point, she’s a straight A student, vaccines are up to date, she eats healthy and exercises regularly, Mom and Dad are still happily married and she’s not dating an abusive senior who is pressuring her into having sex. I anticipate a pretty straightforward visit: We’ll review her history, discuss concerns, perform a physical examination, and hopefully clear her for sports participation.
I am wrong.
Let me preface this by saying that I expect a parent or guardian to be present for at least part of the sport physical visit. This isn’t me being difficult; I need a detailed family history to make sure your child’s safety isn’t at risk, and — more often than not — your teenager doesn’t know why Uncle Bob died at age forty-nine or whether anyone has been diagnosed with a cardiac condition worth mentioning. So while I always appreciate your willingness to give your children the opportunity to discuss their concerns privately, I need to talk to you too — if only for a few minutes.
Alexa smiles and greets me as I walk in the door. She’s alone. We chat briefly; everything seems to be going OK. The visit is moving along pretty quickly, so I ask if there is anything else she’d like to talk about before we begin the physical examination. Alexa looks at me and suddenly her eyes become bright and teary. She rolls up her sleeve, shows me a series of horizontal, superficial cuts along her forearm, and tells me that she has been cutting for the past six months and doesn’t know how to stop.
Based on the current statistics, you’ve likely come across a patient or a friend who engages in deliberate self-harm (DSH). DSH is a behavior in which a person commits an act with the purpose of physically harming himself or herself with or without a real intent of suicide. Some methods include cutting, hitting, biting, burning, pinching or scratching. Studies show that adolescents who self-harm are at higher risk of suicide, drug and alcohol abuse, as well as eating disorders. Primary care clinicians are usually the first to discover that a teenager has been self-harming, and that first encounter can be difficult for everyone — though it is also critical for setting the stage for successful treatment.
Far from being the “master manipulators” that some may make them out to be, teenagers who self-harm are often trying to find ways to cope with overwhelming emotions. Usually the wish to die is not present. That being said, I also encourage you to ask your suicidal patients if they really want to die or if they just want the pain to stop. You will probably find that most are looking for ways to manage an intense amount of emotional pain — an amount that far exceeds their coping abilities. This does not make them weak or faulty — and patients need to hear this from you.
I often encounter patients who are afraid to try counseling because they fear that others will label them as “crazy.” They are under the assumption that asking for help or seeing a therapist means that they aren’t “good enough” or “strong enough” or “smart enough” to deal with life’s notorious ups and downs. They fear that there must be something inherently wrong with them. They fear worthlessness and judgement from others — and with time, these beliefs become engrained — they become their truth.
The hesitancy to seek mental health treatment doesn’t only apply to children and adolescents; families struggle with the idea as well. I have noticed parents getting nervous and rapidly dismiss me when I bring up something related to mental health — like a counseling appointment. Things like “I don’t think we are there yet” or “I think we can handle this ourselves” are some of the most common responses I hear.
So let me ask you something: When will we “be there”? After your child starts engaging in intentional self-harm? After their first suicide attempt? After their grades start dropping or their sleep becomes disturbed? After they discover the roles of drugs or alcohol? Where do you draw the line?
We regularly complain about the lack of primary prevention in America. We talk about “sick culture,” about how we “chase disease” instead of promoting health, and about how we can make sure our patients aren’t using the emergency department as their primary care provider. We worry about the obesity epidemic and about how the rates of hypertension and diabetes are reaching record highs. But when it comes to mental health, we are still keeping quiet, and I struggle to understand why.
Don’t get me wrong: I know that we, as a society, are still fighting against the stigma of mental illness. But as clinicians, are we doing enough? What keeps us from talking about mental health? Is it the lack of time? Do we not feel prepared or comfortable to deal with the realms of mental illness? Do we believe that it is not part of our scope of practice?
We already know that access to care is an issue, and access to psychological care is even more limited. As primary care clinicians, we are bound to encounter suicidal, depressed, or anxious patients, and we have to be able to open the lines of communication and create a successful partnership with our patients and their families. Yes, addressing mental health concerns takes more time and effort, and reimbursement rates continue to drop. That isn’t news.
But let me let you in on a secret: I did not go into pediatric primary care for the money. And if the extra ten minutes I spend with a depressed adolescent makes them feel a little less alone and helps foster the development of a culture that doesn’t immediately shun those struggling with mental illness, then I’ll consider my job well done.
Florencia D. Kantt is a pediatric nurse practitioner and can be reached on Twitter @florenciakantt.
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