Thank you for joining us. My name is Shashank Joshi, and I am delighted to welcome you to our presentation, Thinking About Prescribing. What the Therapeutic Alliance Evidence-Based Psychotherapy and Relational Principles Teach Us About Psychopharmacology with Diverse Youth and Families. And I am joined by my mentor, Professor Karl Feinstein, who will be talking a little more specifically about the work in psychopharmacology as it relates to what we understand to be the dual alliance, the idea that all of our work is relational, the alliance is core to what we do in all psychiatric work. I would say also in primary care, trained as a pediatrician, so I can give witness to that. But in particular, as it relates to the work with parents and the other important adults in the lives of a young person, where we are considering the start of a medicine. So we are going to be speaking through the microphone because it's being recorded. We both have some disclosures. For Dr. Feinstein, he is an advisor for Trait Health, and he'll talk a little more about that work, although that work is not exactly a conflict here, but we wanted to list it anyway. I receive funding from not only the School of Medicine at Stanford, but also from the Lucille Packard Foundation for Children's Health and the American Psychiatric Press. We get royalties on this book, which this is now a shameless plug. This is my conflict. This talk is a lot about the stuff in this book. This book was configured with Andres Martin from Yale, and together we brought together almost 50 authors to talk about this topic. And we're going to, today, highlight some of the very important take-home points from the book, and then we're going to stop with enough time for questions, and we hope you will utilize the microphone there to share your thoughts about your own experience in trying to set up a treatment alliance, what gets in the way, what helps to cultivate it across the different kinds of work that you all do. So our goals for today is really to start with this concept we call the Y model of psychotherapy and how it's applied to pharmacotherapy. In fact, right after this talk, David Mintz, who published the book Psychodynamic Psychopharmacology, is going to be holding a session. It's in your APA app. And that book came out the same year, last summer, along with another book called Prescribing Together, which really, I think, was a game changer for those of us who think about this kind of relational psychopharmacology and pharmacotherapy as we call it. We're going to give you an example of how you might utilize the 30-minute visit. And there's a chapter in the book by Doctors Onglowinsky and Max Rosen. In the chapter and in the book, we propose the term brief pharmacotherapy visit, or BPV, to banish the term med check, med management, med visit. That's not what we do in child and adolescent psychiatry. In fact, according to David Spiegel and Glenn Gabbard, perhaps you've heard of them, they, at this very conference almost 20 years ago, resolved in a debate forum that the med check term is not accurate, it doesn't exist. The name of that was called the myth of the med check. That was back in 2001, actually, more than 20 years ago. We want to identify some techniques that you hopefully will take away, develop from evidence-based psychotherapeutic interventions to enhance adherence. And finally, for you all to be able to list strategies to cultivate your alliance in telehealth. Many of you are still working in telehealth, although hopefully most of you are getting some inpatient, in-person time. And this also includes in the school setting, which is the place where I like to hang out much of the time. So these are the goals. We hope that you'll walk away with these abilities by the end of our session. So why are we all here? You have a number of wonderful other kinds of things you could attend to at 1.30 Pacific time. I'm just gonna remind us that we are in this kind of place where as psychiatrists, we're being asked to do more and more with less and less time. And this quote from Jonathan Metzl, which is now more than 20 years old, but I think it's still very relevant. It is easy to slip into the postmodern disconnect. So much pressure, so many patients, so little time. But the therapeutic interaction at its core is still a relationship between two people and maybe a third person when it comes to the parent. Doctor, patient, parent. And so continued attention to and discussion of the nuances of our interactions enhance the possibilities of a successful and indeed a personally meaningful outcome. And I would say in some instances, a transformational outcome. If we are open to the experience of our patients, of our parents, to hear what they have experienced taking a medicine or contemplating taking a medicine or not. So when I arrived at Stanford in the late 90s, folks like Dr. Feinstein and others really encouraged me to think about the idea of the treatment alliance and that there may be something in what we do in the room that leads to part of the, I guess you would call it the Holy Grail in anything related to pharmacotherapy in any medical specialty is, can we enhance the adherence somehow if we have a strong trust, a strong bond, a strong therapeutic alliance? And that's been shown in research in adult pharmacotherapy. Not as much research in child pharmacotherapy, although there are signs particularly with ADHD that if you take the medicine inconsistently, but you have a strong treatment alliance, in fact, you may have better outcomes the people around you, if you're a young person with ADHD, you're probably going to a school, there are teachers, there are other youth facing trusted adults, they may start to notice a little something different, they may comment on it and that can then enhance your treatment alliance because the parents may feel like, hey, yeah, Dr. J, maybe we should take them back because it seems to be working. But when you do the adherence monitoring, you find out, well, they may not be taking the medicine every day. So there may be something about the treatment alliance that automatically produces better outcomes, that's why it's a bidirectional arrow. So we wanted to understand that and I got my first invitation with Professor Hans Steiner, who has now passed, he died in October, but he convened a bunch of authors from the department to write about different aspects of developmental psychiatry and so I got invited to do this chapter on the psychological aspects of prescribing. And it'd been written about since the 80s and the 90s, John Showalter from Yale, many others talking about the meaning effects in medication. But in this book, what we were hoping to do is bring it into the modern context, highlight some of the research that's been done on meaning effects, on placebos, on expectancy effects and figure out if there was some implication for the way we practice and if it could mean better patient outcomes. And so I began to review the literature and I came across many different writings showing things like Bernie Bightman from Missouri talking about the doctor-patient relationship as really a drug delivery system. Sometimes you see your patients a little more frequently but for less time, like in a school setting, that can mean a lot, that's a little bit of a bolus. If you might see them every month for 45, 50 minutes, if you're in a school setting as I am as some of my residents and fellows are, we might see them twice a week for maybe 20 minutes. We know from Janice Krupnik's work, from the NIMH, from the TDCRP study that looked at different ways to treat depression, that better therapeutic alliances predict a more favorable medication response and that the outcome of our treatment is actually poor if we only focus on monitoring symptoms and side effects. Indeed, one of the reasons we propose the term brief pharmacotherapy visit is because we do pharmacotherapy. We have 30 minutes with a patient, we're probably spending 20 or 25 minutes understanding the other domains of their life and maybe spending a crucial five or maybe 10 minutes understanding the effects of the medicine or whether or not they're willing to take the medicine and what side effects they may be encountering. It's a reminder to us of our therapeutic role. Now, we're not the first to think about it or write about it. I think this is the first book to convene child mental health thinkers and clinicians. We have psychologists, social workers, it's mostly child psychiatrists, but everyone's sort of coming together, including pediatricians. I trained in triple board at Albert Einstein in New York City in the 90s. We're about to start a triple board program at Stanford. Are any of you medical students in the audience? Okay, see, we have a medical student, right? Very good. So we are open for business. We are recruiting starting this July and we'll welcome our first class in July 24. The pediatricians, starting from Milton Senn in the 1940s, wrote about the crucial role in this paper called The Psychotherapeutic Role of the Pediatrician in 1948. It's open access, you can find it on Google Scholar, but he actually wrote about the ability of the pediatrician to just be there, hold space. It's not so much what we do with our patients, it's how we are with our patients. And in the four days he was writing, in particular, about mothers and how the pediatrician can bear witness and hear the story of the mom so that they were better able to care for the children. And so we must remember our abilities as therapists in all aspects of our work. Again, the Therapeutic Alliance has been studied across paradigms as a very effective cornerstone of treatment. When we offer treatment, it's not a neutral act. And yet, there's something about that relationship which is magical, but also elusive. So in this cartoon, the two scientists are at the blackboard and the mentor says, I think you should be more explicit here in step two, where the miracle occurs. So what is happening in your sessions that is miraculous? Well, from our book and from the illustrations of the inimitable Simone Haselmo from Yale, when we think about what we do and when we think about psychiatrists compared to surgeons, there's a whole narrative about, why didn't we go into surgery when we were considering a specialty? And what Andres Martin proposes is because surgery, because surgery does not cut deep enough. And the scalpel is only as good as the hand of the surgeon wielding it. So we might have these pills, but milligrams dispensed are easy, time well spent is hard. Now, we can all say, well, we don't get enough time. And we would invite you to think about time well spent. If you have five or 10 minutes, maybe you have a half hour, maybe you have less. The less time you have, the more important the relationship. So again, you see this very kind of evocative illustration of the clocks as pills coming out of the tablet. And again, the idea that in child and adolescent psychiatry, we're not only dancing with our patients around the meaning of the medicine, but there is inevitably, hopefully, more than one trusted adult, maybe it's a parent. But this is really, it's a negotiation, it's a dance and it continues. Not just after they've agreed to take the medicine, but then even as we do titration or propose medicine holidays or reduce the dose. And then we have a whole section talking about the stance regarding treatment among us as clinicians, as well as the perception of the risks and benefits. And so in this illustration by Simone, you see in the top left, and I don't know if my pointer really works here, but you can see this might be the most helpful, where we have the trust. Maybe acquiescing is a strong term. I don't know if I would call that helpful, but hopefully if the medicine is working, the angels are working together and the pill has some sort of magical, even divine quality. However, we can go through these different squares and you might notice, anyone in the audience, what do you notice here? What comes to mind when you look at this picture and you spend maybe 10 seconds trying to figure out what it is? What do you notice? A gradation from maybe clear and hopeful, bright and white, and it gets a little darker as we go down. What else? The pill, the way it's viewed in the southwest corner, the pill is a grenade. So this is resigned, it's resigned, I guess we will take whatever, when all else fails. Sometimes in school, it's like, well, when all else fails, we've tried the therapeutic use of play, we've tried talk therapy, we've used a structural behavioral intervention, group intervention, might as well call psychiatry. It's time for meds. This is why we propose talking about a medicine as a possible intervention early on in the relationship. And so what we're hoping for is this and we are also hoping to avoid this, where it's a highly stigmatized kind of experience. In schools in particular, we like to propose the idea and then cultivate the notion that mental health is part of overall health, our children have to be healthy enough to learn and our teachers have to be healthy enough and versatile enough with the tools they need to reach and teach every student. So if we're gonna propose a medicine, I absolutely want to get an ROI to discuss it with the teacher, to give them a heads up that we're starting a new medicine or we're increasing the dose or we're decreasing it, because they can actually be our clinical eyes when we only have a half hour every month or every few months. And even if we're meeting with them once a week, that teacher, especially in elementary school, which Dr. Feinstein will talk a little more about with younger children, they are spending 25, 30 hours with that child. So we must empower that relationship. But getting back to the reasons you're all here, the prescribing of a medicine is as much the Colfax of molecules as it is the warm way in which we envelop them for delivery. And that's what we're gonna talk about today. And so Andres Martin, who is professor at Yale, who is the co-editor of this book, could not join us, but he wrote a piece last year in the APA News, which appeared right before the annual meeting in New Orleans. It was called Prescriber, Prescribe Thyself. And whenever I inscribe one of our books for our trainees, I always make sure they remember that. And that gets back to the notion, really, that Milton Senn, as a pediatrician, proposed in the 40s, yes, it's important about knowing our medicines and knowing our interventions and what we do with our patients. But how we are with our patients is at least as important. And that is where the article moving from our pills to our person begins. And then we continue throughout the almost 50 chapters in the book. So let me start with the why model. How many of you are familiar with the why model in psychotherapy? So it's a concept that's been around for some time. And Dr. Eric Plakin, who is at this meeting, wrote an article in 2009 that describes it in a little more detail. And then Magdalena Romanowicz, who is the program director at Mayo School of Medicine for Child and Adolescent Psychiatry, was a fellow of ours. And as is true with so many of our trainees, taught us at least as much as we think we might have taught her and continues to be a leader in psychotherapy teaching. The why model essentially is the idea that the core, the stem of the why, these are the basic tools that we bring in where we talk about the goals in psychotherapy, the tasks that may be overtly defined for the therapist and the patient, the collaboration. This is all in psychotherapy, okay, and whether we're moving from a more psychodynamic psychotherapy on this side of the Y to a more, say, treatment-focused, time-limited, manualized treatment like in CBT, if you don't have the stem of the Y, you will never get to the branches. And so in all aspects of medicine, in particular youth-facing medicine like pediatrics, family practice, and especially child and adolescent psychiatry and even general psychiatry because Eric Plaken wrote this about psychotherapy in the context of working with adults, we must remember the core components, the common factors. And so what does it mean for us as pediatric pharmacotherapists? What exactly do we do to help the patient feel that they are caring, trustworthy, and credible? Well, I believe that something we can learn from CBT is to open ourselves up intentionally to tell our patients a little bit about what they might be curious about. And I stick to the things that are in the public domain. I don't try to burden people with our personal story. But sometimes in the context of a relationship, a little disclosure can go a long way. And this is where we have to be conscious of our boundaries, but we also understand that a teenager in particular might need us to kind of keep it real and have a conversation that to them feels very authentic. Number two, what does the pharmacotherapist do so that the patient and their parents believe that their problems are understood from their point of view? This is where we get into the dual alliance, which is exquisitely important in psychopharmacology and youth and young adults. And then how do we ask about adherence? What kind of language do we use? And in Magdalena's chapter, she intentionally uses the word adherence instead of compliance. I don't know if you're using that all in your practices, but I see a lot of nodding heads. So the stem of the why, as I said, this is our opportunity to establish rapport, foster an atmosphere of safety and trust, and it allows us to really relate with what we hope to be genuineness and empathy. We use reflective listening and it really cultivates the idea of connection. Because if you're going to talk about adherence or if you're noticing that they're having trouble getting to the pharmacy or they're not taking the dose as prescribed, connection before correction. Again, that's very interpersonal, but that also comes out of PMT. That's Rebecca Riellon-Berry who taught me that, who ran the PMT program at Stanford for many years before moving back to New York. But I think that's important for common factors. Carl, before we move to cultural aspects, do you want to say anything more about the stem of the why, especially as it relates to the work with parents, especially parents of younger children who might be coming in and considering agreeing to have their child take medicine? Right. So when I discussed this presentation with Shashank, I reminded him that my last several years of clinical practice have been with young children who, as opposed to walking into the high school and talking to a 14 or 15 year or 16 year older, and all the pitfalls. So I want to keep coming back to the importance of the alliance with the parent. Childhood is, I guess for me, a very short time, but for the parent it's a very long time. And the differences that happen over a few years in a child's ability to participate in their own treatment are enormous, but for the young children, it's much harder for them to conceptualize even what the problem is. And it is, you cannot get anywhere with the younger, and the parents often come in, as we've talked about, basically wanting, with a defensive posture, what is this child going to do, what is this doctor going to do to my child to give them a medicine that might hurt them or might not be safe? So establishing trust, establishing rapport, establishing partnership, collaboration, and listening to how they understand the problem is very, very critical. With the younger children, you can't get anyplace without that, and much more can be said about that because it's not only a very personal issue for the parents, but there are all kinds of cultural issues that come into play about parents' attitude towards medication and what they know about it. And then for the child, you still have to form an alliance with a little child, too. But if you ask a five-year-old or six-year-old who is routinely getting thrown out of class or sent home what the problem is, they may say, well, kids are bumping into me too much. They don't necessarily see the problem as something inside of them at all. So there's the extra challenge that you have in communicating with a child to find out from them how things might get better. So I always try to, both with the parents and the child, we're going to get more to this later, I know, I don't want to take too much time here, but we have to find out what the parents' goals are and what the child's goals are, and try to focus our collaboration with them on helping them achieve their goals, because they're the patient, and as I am always saying to the parent, you're the parent, you're in charge, my job is to help you. So we'll come back more to this later. Thank you. Yeah, that's a great segue, actually, because I would say, and we teach in our program, that every interaction is cross-cultural. You may be working in an Asian diaspora clinic, I was just on a presentation with May is Mental Health Month, as you know, it's part of why APA falls in May, but May 10th was AAPI, or AANHPI, for Asian American, Native Hawaiian, Pacific Islander Mental Health Awareness. And trust is key, not only in the Asian diaspora, but we were talking about that specifically, especially when you may come from a family where mental health is not talked about at the kitchen table. And so part of what we do in schools and in early childhood is work with parents, work with school boards. In California, we actually have a law that allows us to not only teach about mental health and suicide prevention from K through 12, it's now the law, but we also have to teach about mental health in any curriculum on health. Now, the folks at the state have not told us exactly what to teach, which is okay, it's a good thing and a bad thing. Unfortunately, we find in the audits that sometimes districts are just checking off the box, other districts are doing it extremely well. But trust is key, and if we are working with parents, it's very important that we understand what their concerns are from their point of view. And so if every interaction is cross-cultural, it's particularly important if we have a family of newcomers or a family whose ethno-cultural background is very different from your own. And so really asking about that. So many of you may know that in February. One more point. As part of this process, there's also a big difference from where the child is coming from and the parent is coming from, which I'm sure you've all encountered. So you may want to ask questions about how do we deal with that? How do we deal with a child who's hanging their head down while the parent is saying everything that's bad about the child? And basically, and you're sitting there saying, oh my God, this child isn't even going to talk to me after this. So how do you avoid being the agent of the parent to the child? And also, there may be times when you have to talk to the parent without the child, or you may have to talk to each of them separately. I just want to point that out. Well, I learned that from you, Carl, when I was a new faculty, that a key part of how you can cultivate the alliance is reaching out to the parent for a few minutes before your new intake. What a concept. I know you can't bill for that, but listen, 10 or 15 minutes with the parent on the phone, having been that parent who's taken a struggling teenager to a new therapist, makes all the difference. It sets the alignment in place for the trusting relationship. This doctor, this therapist reached out to me, they wanted to talk to me for a few minutes to get the story. And in those moments, when I first arrived at Stanford running an ADHD clinic, mostly boys 6 to 11, mostly in trouble, some with ODD, some with just a lot of disruptive behavior. In that connection with the parent on the phone, you kind of let them know how this is going to run tomorrow, what do you think, we'll spend some time together, then I'll spend some time with you, but I want to end with the child, or I'll meet with the child in the beginning, whatever the parent thinks will work. But I also cue the parents, when we're meeting together, this is your chance to highlight what your child is good at, what you enjoy doing with your child, what you look forward to doing as a family. And the reason you do it before the visit, because in the visit, the last thing you want to have happen is for the parent to have a deer in the headlight look when you ask them about strengths or things you enjoy. Because they may have forgotten what it was to enjoy time with their child. So give them a heads up. And this allows them to really talk about the strengths of a child and not just, okay, as a pediatrician, well child checks, we do a lot of anticipatory guidance, we talk about strengths before we talk about challenges. As child psychiatrists, by the time they get to us, there's probably been a lot of people taking a look at, and the child's experiencing, oh yeah, I'm the problem, and everybody thinks I'm the problem. So you may have heard that we had this tragedy in Half Moon Bay, which is a community about 25 miles south of here. We had a number of migrant farm workers, most of whom were of Asian descent, involved and victimized by a mass shooting. And the two shooters were actually elderly Asian immigrants themselves. So you might imagine, you know, all the implications of that and, you know, the background of the people who were the ones who, you know, took the lives of these others and, you know, in a fit of rage, but also probably with their own stories, whether it be war trauma, immigrant or refugee experiences, et cetera, but then there was this horrible tragedy. And so asking about that in session was very important for us, not only among Asian diaspora patients, but also just any patient, whether they're immigrant or not. There's a term that we use in the field called IROI, immigrant and refugee origin youth. And so, yeah, they may have heard about it on the news, they may have seen it on the social channels, and so, yeah, we should be asking about it, particularly if we're working with an immigrant community, minoritized community. So we have 65 million children and teens going to public school every day. 25% are immigrants or children of immigrants. And so that is, in the Bay Area in particular, it's more like 30 to 40%, depending on what district you're in. So we have to understand what we bring to that. Hopefully we bring a curiosity and a humility that helps us really understand the patient's story, but we also will have implicit bias. It's part of the human condition. And so understanding our own biases and learning to mitigate them with specific strategies is very important. Now, our very own Amalia Londonio-Tabon, who finished medical school at Stanford, went to Yale in the integrated program, and is now doing maternal child mental health research, wrote a paper on racial implicit associations in psychiatric diagnosis, encouraged us all to take the IAT, which is available online, to really tap into our own implicit bias. And again, I would say we invite you to think about every interaction as cross-cultural. So if we can strive to learn about the communities and the cultures that our patients come from, if we can take the implicit association test, it probably gives us a better chance to not be stereotyping, because we're going to try, okay, we know something about the patient's background and culture and their immigrant history and what country they came from, during what era, but at the end of the day, this is one patient and one family in front of us with their own story. So the background helps us. It invites us into the kitchen table to the conversation for dinner, but will we get invited back? Well, if we do a good job in that first session, or the research tells us with adults, the therapeutic alliance is established by session what, would you say? What's the range of sessions we need to pay attention to our alliance? By when do we establish an alliance in psychotherapy? Anyone can throw it out. Is there a range? You might guess early, late, five, okay, someone said five, good, yes, middle to late, actually, it's fairly early. It looks like it's around session somewhere three, four, five for an adult. With teens, it's a little more elusive. Some teens will size you up and let you know, tell their parent or not, like, yeah, this doc's cool, I'll see them, or no, I'm not going back to that doctor. They may size you up pretty early. With younger children, they rely a lot on the impressions that their parents have on the car ride or the bus ride home. What kind of conversation did the parents have about the doctor experience? Or even in the room. Or in the room. Or in the room. They notice how the parents are relating to the doctor, and they pick up. They pay attention. They pay attention. The children are watching. So we try to teach about this, individuate them versus stereotyping them, creating a broad differential, recognizing situations that might magnify stereotyping and bias, and then this concept of cultural humility, where everyone comes with their own background and story, and that every encounter is cross-cultural. So if we remain curious, if we can take that from mentalization-based therapy and mentalization techniques, always remaining curious, that will serve us well. So I'm going to move right now into, for the next few minutes, to talk about a chapter that was written by John DiLallo from New York, formerly from NYU, and he wrote a really important article in 2009 in the Orange Journal, Journal of Child and Adolescent Psychiatry of the Academy. And he talked about adapting motivational interviewing techniques to enhance adherence in teenagers. And so we reached out to him, Andres and I, when we were putting the book together, and he was really interested in highlighting three of the paradigms that he has found useful. Again, this is someone who is now mostly in private practice, mostly doing pharmacotherapy, and has learned to adapt, because he's been trained in the techniques, to utilize principles from DBT, from motivational interviewing, or MI, and from ACT. And so, in DBT, obviously the idea is that emotional dysregulation can come from this combination of a temperament, a reactive temperament, and invalidation, a history of being invalidated. Typically from when a young person becomes a teenager. We often see the first expression of this maybe in early to middle adolescence. In MI, we are looking at trying to connect with the patient where they are, or meeting the teenager where they're at, whatever term you'd like, and try to resolve the ambivalence with regard to making a change. In this case, as it relates to medicine adherence. And then in assessment and commitment therapy, or ACT, identifying the core values and developing the kind of psychological flexibility to live by them. And there's a really nice online tool that you can do, and your patients can do for free, to get a sense for what their values are. And that is the VIA, or Values in Action, survey that was proposed by and maintained by Marty Seligman's group at the University of Pennsylvania. I see some nodding heads here. So the father of positive psychology, back in the late 90s and early 2000s. And one of the things he's done over time, and honestly, his graduate students and the other folks who've gone on to develop the theories of grit, and the theories of mindset and others, is to allow us to tap into, well, what are our values? What are the things we hold dear? And so the VIA survey is nice. There's a youth version, there's an adult version. I invite you all to take it. But if you're using an ACT approach, it's nice to know what the patient's core values are. It's sometimes hard for them to sort of name them. But John talks about this a little more in the chapter in the book. So he thinks like, okay, now as child psychiatrists, like what am I? Am I a doctor or am I a PEZ dispenser? And I don't know if kids today know what PEZ is. They still sell PEZ in the big box stores, I think. There is actually a PEZ museum in Milwaukee, if you make your way there, with all the different, there's also a bobblehead museum there. But so he just sort of proposed this. It was sort of comically, but actually the reality is sometimes our patients see us that way. More often, the parents may see us that way. And this is really not what we desire. But if that is the reality, we might ask ourselves, what kind of dispenser do we aspire to be? So you can think a little bit about that and which character you might connect with. But I think for me, I have learned and Andres has learned, we work a lot at the neuropsychiatric interface between receptors and pathways, primary care and mental health, inpatient and outpatient. And we might want to employ a medical model, and that can be extraordinarily de-stigmatizing. I always wear the silver ribbon pin from NARSAD. Mental health conditions are brain conditions. I know someone with a brain condition. I care about them. I care about having this conversation. If you wear the silver ribbon, people will ask you, what is that ribbon you're wearing and you have the conversation. For parents in particular, if they can learn that this condition actually lives in the brain. Asthma lives in your chest. And this can be a de-stigmatizing conversation for some people. But for others, as you see from this young girl there, this adolescent who's trying to close her ears, she's tired of people telling her what's wrong with her. But if you can talk about what's right, you have a great brain, it works really well. And what happens in ADHD is the following. Your brain learns differently. You process things. There's a lot of noise out there. It's hard to focus on the signal. When do you focus on the signal? Oh, when I'm reading my whatever it is or when you're playing the video game or you're interacting with a friend or playing a sport. And so you can use that to enable the discussion I talk about in that case, signal to noise ratio, focusing on the task at hand. So it can be useful, but we ought to use it cautiously. And then this idea really that John highlights is that when we are in the helping profession and if we're using medicine, it's about clarifying what meaningful improvement is from the patient's perspective. Because like what's in it for them? My parents want me to take these medicines. They're the ones that are crazy. Why do I have to take the medicine? My parent is going off the handle. I know they're stressed at work, but they come home and they're just like, I'm walking around on eggshells because they've had a bad day. Why do I have to take the medicine? And so what we're trying to focus on in this section is that these kind of more process-oriented therapies allow us as doctors to really get into the patient's relationship to these experiences around them. And these strategies we can use are very important, especially when they're going through a tough time. We want to avoid having them say, well, I'm having a hard time, so I need my pills. But rather, well, I'm learning some tools. I'm learning some skills in therapy, in talk therapy. I'm practicing some things, some exercises. The medicine might help me do that work a little better. The medicine might help me be a little less frustrated and a little less cranky. And yeah, maybe it can help me be the best version of myself, but again, that gets tricky because teenagers may ascribe a lot of meaning to the medicine. Am I the real me on Prozac? Or am I the real me off Prozac? And what does that mean? So for us, as pharmacotherapists, we need to understand from their point of view, what do they think about it? What's in it for me? This is what they're often thinking. And so if we can discover what that is, then we might be able to enhance our alliance, enhance adherence, hopefully, and provide this therapeutic benefit throughout the course of their treatment course with us. Now, very briefly, Telepsych. Now, very briefly, Telepsych. Telepsych now, thankfully, we're not having to rely on it as much because we're coming back in person. But one of my school's mentors, Jeff Bostic and David Kaye, who was the program director for many years at University of Buffalo, they wrote this section on kind of the four core components of telepsychiatry. Actually, this was part of the ACAP practice parameters in 2008, way before Zoom was a thing. There were best practices for practicing in telehealth. So, of course, we want to be clinicians who are interested and we want to be able to utilize the modality to deliver care most effectively. We also want to make sure that we're attending to who are the interested, invested, and impacted parties, caregivers, school staff, the people who are committed to collaboration. So in our training program, we have a very active school mental health service. And sometimes the kids won't come to school. Maybe they're school avoidant. Maybe there's a reason they couldn't get to school. Maybe they had to look after their younger sibling because both parents work outside the house. And so they're going to miss school that day. Well, our therapists are versatile enough to know that they can still get on the Zoom, send a Zoom link, and that young person will get on their phone or get on a computer. In a lot of our Bay Area counties, the districts actually were able to partner with a lot of our tech companies and make sure that there was good Wi-Fi available for every student of every district, even those that are under-resourced in general. And that continues. I would say that was a silver lining. So we have the ability to get in there. Notice I use the term interested, invested, and impacted parties rather than stakeholders. Any ideas about why we like to talk about it in this way? Stakeholders are, that is actually an older term, and it's starting to fall out of favor. You know, if you are a landowner of a certain class, you can put the stake in the ground and says, this is my territory. And a lot of people who had that territory, for example, you had the invocation here among the Ohlone Indian tribes. We are on Ohlone land right now, and stakeholders decided it was gonna be land used for someone else. So we have found the term interested parties, the people who might be curious, oh, you wanna use telehealth, it might be hospital administration. How are you gonna set that up? Is it reimbursed? Have the insurance companies are an interested party? How are we gonna continue it post-COVID? The invested parties, like clinicians and patients, they might like the flexibility. And the impacted parties, which are, of course, gonna be our patients first and foremost. And that actually came from Derek Heck from the School of Education, Grad School of Education is doing work in this area, GSE at Stanford. We need coordinators so we can get the right space, and we need system supporters. So this is probably very familiar to you all, but they also wrote about the alliance. What is tele-rapport? How does that help us? What is it favored by? Kind of a casual style by the clinician. Glitches are bound to happen. Do you know what to do when there's a glitch? Demystifying what happens when there's a glitch and having a plan B. Really showing the controls, if it's the first time for a patient in telehealth. And then for child patients in particular, having adults present. We want adults present to be able to structure what's happening. A lot of our play therapy interventions were happening on the kitchen tables, and the bedroom floors, and the basement floors in our patients' houses. I mean, that was extraordinary for us as clinicians, and it could be great for the kids and convenient for the families. It can also be rather daunting and threatening, depending on what the family's experience is. Maybe they've never had a home visit or a virtual home visit. So we have to attend to that within the frame. Okay, so moving back to now, the factors that we know from research has affected medication treatment. We have patient characteristics, we have the characteristics of the adults, maybe some school factors, peer factors. Do any of my friends take this medicine? We have the media, how is medicine, people who take medicine, how is that portrayed in pop media, on the social channels, among the YouTubers they follow? And all of those factors are going to go into the psychology of when a young person takes medicine. So there are a lot of things to consider, and this leads us now to keeping all these things in mind. If we have a 30-minute visit, how might we spend that time? So this is not prescriptive, per se, but it does offer some nice ideas about how we might use the first 20 minutes of our BPV with the last five or 10 minutes talking about the medicine. And so there's some examples here, tending to rapport, really even some of the phrases you might think about using. You know, I've been thinking a lot about our last visit. What do you think about this? When you give that phrase, I've been thinking about our last visit, or I've been thinking about you since our last visit, how did the game go? You know, it is a reminder to that person that you're important. Yes, you have a busy clinic, you've had tons of patients that day and that week, but that family's coming to you for that one visit that week or that month. Number two, getting updates on environmental influences. I like the head's mnemonic. It's an oldie but a goodie. Do you know the head's mnemonic? That comes out of family practice. Attending to the major domains of a young person's life, home, education, activities, distractions, drugs. The S used to be sleep, sex, and suicide, but we add other things now. Spirituality. You know that even if it's a secular spirituality, young people have a very engaged inner life. We have to tap into it, or we're gonna miss a major domain of understanding who this young person is. They may be connecting to a cause, a political movement. They may be connecting to a group of other people who think about something similar. That's an important way for them to have a sense of belonging. We know that having a sense of belonging and connection is very important for a young person's well-being. It's also important in suicide prevention because a disrupted sense of belonging can feel very, very lonely for a young person. So we have to really encourage that. We have to ask about it. So that's another opportunity we have. We talk about the D for distraction. It also leads us to things like media and how much time they're spending on media. We just launched in the last four years an adolescent addiction program at Stanford Children's Health. In that program, we have clinicians, we have researchers, and about 30% of the clinical presentations are not for substance abuse. What are they for? Gaming addiction, internet addiction. So asking about that in the environment's very important. We can ask about who they follow, what social channels they're on, who are their favorite YouTubers, how do they stream their music, but it also allows us to tap into how much time they're spending. Did you have a comment about that? Oh, well, I was thinking that a lot of kids bring up, a lot of my fellows are asked, what games are you playing? A question I think that the older people avoid because they don't know what the games are. But it is a tremendous advantage that the fellows are young enough and play these games. So they know, and they can say, oh, what'd you do in that game? It's a very good basis for establishing rapport instead of dismissing it as this problem behavior that's getting in the way of their getting good grades or whatever. Yeah, great point. Great point. We need our fellows to teach us about what the latest version of Red Dead Redemption or like whatever the game might be. So yeah, crucial. That's why we stay in this field because we're always learning from our students, residents, and fellows. And you notice like in this diagram from the chapter that Angielinski and Max Rosen wrote, we get to the medicine like in steps five, six, and seven. Are we gonna maintain this medicine at this dose? What do you think? How are things going with your other therapy? How are things going in family treatment? Like just talking about treatment in general allows us to then in step six and seven talk about the medicine. How do you think it's working for you? What problems are you seeing? Are you able to take it every day? And then any other things we should cover today? And if you get into the rhythm of tapping into these major domains, you'll find that the treatments you offer are in the context of this relationship and you'll find your visits to be more meaningful. And you'll hopefully banish the term med check, med visit. So Kyle Pruitt, who is under Smarten's Carl Feinstein, we devote this book to our two mentors, Carl being one and Kyle being the other. So you'll see it in the, this is like totally shameless plugging, I'm just owning it. But there's a picture that Simone drew of Kyle and Carl it's a cartoon. And it's a way that we finish the, we end it in this chapter called Prescriber, Prescribe Thyself. And you can't see it here, but there's a picture of Andres and I thinking about our mentors. You know, what would Carl do in this situation? But children, they have very interesting ideas of being on medicine. Yes, we prefer the term medicine over medication because children know about taking medicine from a very young age. They may have had medicine for a fever, medicine for pain. They may have had a bandage put on. But they have interesting ideas and why they're in treatment or being medicated. So this chart from a chapter in the core textbook in pediatric psychopharmacology is called Children, Medication, and Meaning. And it taps into some of the beliefs or fantasies that children may have. For example, the physical properties of the medicine itself may be relevant. It may be useful for adherence or not so much, depending on the association. If it's a large pill or a small pill, if it's a liquid medicine that tastes good or tastes bad. Perish the thought if we have to use injections, you know, and particularly on inpatient units where a lot of our kids come from a trauma background. Size, the bigger the pill, the more serious the condition or the more powerful the condition. And the child might feel like, well, yeah, I need 200 milligrams of my medicine, but my mom only takes 10 milligrams. It might be a different medicine, but in the child's view, very concrete. They might be just paying attention to the number of milligrams. Sometimes parents pay attention to the number of milligrams and may get stuck on that. Labeling, printing, personalized associations. We tell some stories about, for example, a child with ADHD who felt that the little imprints, the numbers and the letters on each side of the pill were secret codes to help blow up the monsters that were getting him in trouble. And so taking the medicine for him, something he came up with, was an important part of his getting better and be able to be in better control of his behavior. Timing of the dose. More means I probably have, I'm in more trouble. We always try to do once a day, but then how do you time that? Is it that we take it in school? If we take it in school, maybe it's less stigmatizing, maybe it's more stigmatizing. Who administers it? Self-administration may be good if a teacher or parent administers that they may be acting as our agent that may get in the way of adherence. And so as I said, John Showalter was writing about this in the 80s, carrying on a relationship with the pill itself. What is the actual role for medication? Is it healing directly? Is it removing obstacles to self-healing? And this was something that John wrote about in the 80s. And we've thought a lot about this as it relates to teenagers and their developmental tasks, being able to feel like they are the best selves, whether or not they take the medicine, but maybe taking the medicine allows them to do certain things that are important to them, whether it's in their relationship with their romantic partner or as a teammate or just getting through their life, being less irritable. And so when we think about how and when to present the idea, we definitely want to introduce the idea of medicine as a potential intervention early. Even if we're, say, it's garden variety OCD, we're gonna start with CBT, that's the gold standard, but we may wanna have the conversation about medicine early on, because that avoids having to say, oh, I must be a failure as a patient, I have to take medicine now. But rather, if we can introduce it at the very beginning as one option, and first we wanna find out, we might start the conversation like finding out from the parents and the young person, together or separate, how do you feel about medicine for treating conditions like OCD? Do you know much about it, do you have any questions? But if we can discuss it at the outset, it really allows for the most open discussion. And we know that as it relates to adherence, it's very important, first, that we have the stem of the why, the common factors, we want to know everything we can about the treatment we're about to recommend, and we know that insurance can be an issue, we know that how easy it is and how many times you have to take it, but importantly, side effects. And so, if we start with that alliance, we can have better outcomes, but we better make sure we can pay attention, even to the less common side effects, so we're prepared for them, and really understanding what's the level of the message we should be delivering. So for the parents who are coming to us because they've been to two or three or four other doctors, they're probably pretty knowledgeable, I'm not gonna make that assumption, but I am going to ask, and I'll probably get a sense in that first visit about how much reading they've done ahead of time, again, we live in the Bay Area, so often my parents are educating me about the latest side effect that's been reported, or the latest treatment, but Sabine, Byron Hack and Sabine Chow, in the early 2000s, came up with some research-based techniques, and we haven't seen anything new since then, they're pretty practical, we came up with a mnemonic, the sillier the mnemonic, the easier to remember, right? So the mnemonic is, talk does foster superior patient care, and we underline the letters there, this is the mnemonic, T for therapeutic alliance, that's why you're all here, that's why this book came out, K is knowledge and education regarding the medicine, knowing the side effects, backwards and forwards, remembering that the most common side effect is no side effect, but for your child, they may encounter some other things, here are things to keep in mind, really even talking about things like suicidal thinking in the context of the most common side effect is no side effect, but here are the things to watch for in the first few days, in the first few weeks, and if you are concerned about anything, please call me, or call the office, so they should always have a way, if this could be like behavioral activation, they should know how to get a hold of you as soon as possible. Dosing frequency is important, obviously Q day works better than BID and TID, scheduling of the doses, if they're gonna take BID dosing under the option of an after school dose, and if they have a snack waiting for them, it could be the nurse gives it to them in school, right after school, before they get on the bus, or it's at dinner time, or whatever it might be, so scheduling of the doses, that's S, talk does foster superior, P for patient is palatability, it's interesting that children will take the medicine, even if it's bitter, teenagers will as well, if they're bought into the medicine, the people who have the greatest trouble with taste of the medicine, is typically developing adults, and those with developmental disabilities, who might get, might really focus on that sensation of the bad taste, but kids outdo adults in their palatability, and then finally cost, accessibility, insurance, so there you have it, talk does foster superior patient care, that was from the Silver Journal in 2001, an oldie but a goodie, and then again, we said culture is everywhere, every interaction is cross-cultural, and so in 2010, Andy Pumariega from University of Florida and I put together about 13 papers in child and adolescent psych clinics in North America, looking at cultural issues in pediatric mental health, and in that convened set of papers, there was one written by Mansoor Malik from, and Bill Lawson, James Lake from Arizona, Mansoor and Bill Lawson were at Howard at the time, and myself, looking at the adaptations we make in different cultural communities, everything from really being knowledgeable about ethno-cultural differences in metabolism, right, Asian diaspora patients, maybe slower metabolizers at cytochrome P450 at 2D6, we may see a greater response in a shorter period of time at a lower dose, so everyone doesn't have to be on 20 milligrams of Prozac by week one, actually, depending on who this patient is, they may respond to a lower dose, that doesn't mean we may not need to get to a higher dose, but we like to, I learned from Harvey Kranzler at Einstein, we were dealing with some of the most difficult to treat symptoms in teenagers with early onset schizophrenia, start low, go slow, you might need to go fast later, but the last thing you wanna do is give them a really bad side effect, really bad headache, really bad diarrhea, keep them up all night in that first one or two or three days of treatment, that's a great way to sink the alliance, start low, go slow, and then go up as you need to, but also, attending to family experiences with medicines, cultural beliefs about stigma, meaning effects, who else is in the house, maybe you have an elder person in the house who's not so sure that medicine is the right idea, they didn't come to the visit, but you have a parent who believes in it, a teenager who's not sure, why do you help them work through that? We know there's a lot of integrative treatments being used now, CAM treatments, in fact, the majority in pediatrics who come for treatment with ADHD have thought about or are trying some sort of alternative, what we call alternative intervention, so they may do this without informing their primary care clinician, we gotta ask the question in a very open way, if you're gonna ask the question, be ready for the answer, be ready for the answer for what kinds of things they're trying. I'd like to add a couple of points here, maybe this is a little bit out of the box of this presentation a little bit, but I make a distinction about medication between the therapeutic alliance, which we've been talking about the whole time, and what I call the treatment alliance, which is something more specific, and what I try to do is when it is possible, and it often is, to involve the parent or if anybody age and the child or the teenager as much as possible in some of the decision making that has to be made. I say, look, we have a journey we're going on, and there's some choices we can make. We can start at a very, very low dose, it may take longer, it may take a few more visits, but we're less likely to have side effects, but if your child is having a lot of problems right now, you know, we wanna think about that. On the other hand, if we go at a higher dose, et cetera, et cetera, so I explain that all to both of them. Often there are different kinds of medications, the parents, there are three or four different evidence-based medications, and we go over all of them, and go over the safety versus the risk factor involved in the medication, the side effects. Many parents are concerned about sedation a lot, and we set out about a course. They may say, I may say, well, you know what, your chances are better of getting a treatment response with Ritalin, I'm making that up, okay. But they say, you know what, I hear bad things about Ritalin, can we try guanfacine first? So I say, let's go over that, you're the parent, if it's the parent, or it could be you're the patient, and the decision is made together. So you can't have that discussion unless you have a therapeutic alliance, although that helps a therapeutic alliance, but then you can have a treatment alliance, so you have agreed upon a specific plan and approach. So sometimes, I work often with kids with a lot of developmental disabilities and neurodevelopmental problems. I say, look, the first medicine may not work. We have four medicines we can try, here's the safety profile, here's the activity and potential benefit profile. We may, if you choose this medicine, I'm not sure that you'll get the fastest result that way, but if we're working together as partners on this, if it doesn't work, we make a notch on the belt, we write it down on the clinical record, we know now that this medicine doesn't work, and we have to try another medicine, and that's a positive step forward that we can agree to. So I'm getting into the weeds here a little bit about the treatment alliance, but I find it very, very helpful that parents and the kids feel they're given as much choice as possible about these things. They're much more likely to give it a try. Yeah, absolutely. That's really not getting in the weeds. Those are the details of what we do. As it relates to this topic around complementary and alternative treatments, or CAM treatments, or integrative treatments, remember its role. Again, I'm here in California, we're here for this meeting, but when I was coming up as a pediatrician in New York City at Albert Einstein, I had one of my most, to this day, trusted advisors. I could not have a discussion with him at that time in the early 90s regarding IPV versus OPV, injected polio vaccine versus oral polio vaccine. I mean, he was just aghast that this family from France, where by that time the oral polio vaccine was not used anymore, because that parent reminded me, last year in the United States, there were only five cases of wild-type polio reported. They were all from OPV. I want IPV for my child. Why is it so hard to do this in the US? In France, we only use IPV. I was like, I don't know. Let me go ask my team member over there, right? Those of you who were students or residents in graduation, you know, the speech are like, you will no longer be able to say, let me go ask my attending. But I was an intern at the time, so I asked my attending. And he was just aghast that somebody, he's like, they have no idea. They never saw meningitis growing up. None of our residents ever saw that. And so that's why they're not really militant about how every single kid needs to be vaccinated with everything. I was like, okay, what do you want me to tell this parent, right? And he didn't have a lot of ideas for me. And now it's a core part of pediatric training to really understand what is the parent's concern, what's their point of view, what's their experience, what have they seen on the interweb. And, you know, you hear these narratives. I mean, you can read all the science about, there is absolutely no association at all between the components of MMR vaccine and the development of autism. And yet you will hear parents talk about, well, I mean, it's known that they can have a severe reaction. It's known that they used to use mercury as a preservative. Do we have a safe dose of mercury? Like there are all kinds of things that they may be anecdotes, but then when you're a parent, you go into mama bear, papa bear mode, you wanna know that this thing you're about to inject in my child is the safest possible thing in spite of all the things you're hoping it will give in terms of benefits. So sometimes a conversation about an alternative approach or a CAM treatment can be the beginning of a good alliance because you have opened the door, you have come into that door. The parent's trying to open a door to a conversation. As it relates to us in pharmacotherapy with children, it may be that that helps us to at least get the treatment alliance, as you said, get it going, have a team. I had a patient in the neuropsychopharmacology clinic, which we started in 2005 from a Harmon Endowment Grant. You were there at the time. Dawn Duane, who's our partner in pediatric neurology and I started this clinic. We got some seed funding. And her experience as pediatric neurologist, where there were all these kids with psychiatric comorbidities that many of her neurologic colleagues did not feel comfortable treating. And I also encountered in psychiatry that they weren't comfortable treating on top of these neurologic conditions. So we formed this clinic and we had a patient there 13 years old, developmental disability, nonverbal, but still pretty functional, actually could do a lot of things, went to school, enjoyed learning academic activities and engaging, actually learned to read as measured by comprehension, still nonverbal. Her thing was impulsive aggression and a lot of anxiety when she learned that her mom was expecting a sibling. And they came to us and they said, look, we're not interested in psychostimulants. We're too worried about side effects. What else she got? I said, well, omega-369 fatty acids. And the Marlene Freeman article had just come out. It's a randomized trial looking at 369s for omega-369s for ADHD compared to placebo. I said, you know, we could use like a gram three times a day of this alpha linoleic acid and here's how you could use it. And they walked out of that visit feeling so relieved because they had been to three or four others who were like, no, it's ADHD. This is what the science shows. You gotta start with a stimulant. And they were like, what else you got, doc? So they were on that for about a year and she had some benefit. The baby was born. She actually was able to listen to instructions and, you know, sort of not be so aggressive. She was so excited to be a bigger sister but also sometimes with a little aggressive and not realizing kind of where the middle point was. But there came a point where it just got to be too much. It was beyond what the omegas could do. And that's when they came in and said, I think we're ready to reopen that conversation about Adderall. Tell us about Adderall. What's the lowest dose we can use? Would you be willing to, you know? So that was a nice example of how the CAM treatment can actually be a way to continue to hear where the patient is in. With the NC, what is the complementary website? The NIH has, if you just do CAM treatments NIH, there's a clearinghouse looking at what are the treatments that have been evaluated for evidence that come into the complementary category. I think openness about this is absolutely critical because otherwise, as you've really already mentioned, the parents are going, or the child is going to be not doing these meds and just not telling you about them. Or they're not going to be adhering and not telling you about that. Or they're going to be afraid if they see something, if they don't feel they can discuss all these things openly with you, they are going to feel that if you recommend a medicine and they don't like its effect and they stop it, that they can't come back to you because you'll be angry at them. Yeah. These are all real life here. And anger and therapist irritability is actually shown in the research to be something that you can imagine really dings your alliance. And so anger, irritability, I put that together. NCCIH, National Center for Complementary and Integrative Health, they've dropped the term alternative which I really like because integrative is a more holistic term, it's not pejorative. It's like, well, we got our stuff and we got the alternative stuff. Like, well, we have an integrative approach. So anyway, NCCIH, really nice website, lots of resources there, whether you're a clinician, whether you're a consumer. One more point which is very practical here for some of you and even where you're from is that a fair number of parents are using CBD, marijuana and they feel they can't talk to you about that. And that, you can get into a lot of trouble by not having openness about that topic with them too. I just wanna throw that into the mix here. Yeah, so really understanding what, I mean, we know that, for example, CBD is now a game changer in certain kinds of epilepsy. And that is because of, I think partly because of the legalization of recreational use, it allowed for more availability for study. Of course, the problem is that in states that had early legalization, you saw greater and greater rates of early use by youth and school dropout rates went up and truancy went up because those who are most at risk for this greater availability availed themselves. But that should not get in the way of having conversations and thinking about medicinal use, especially now that we're gonna have some data, so. Yes, it's possible to disagree. I have had little kids whose parents were just gonna go ahead and see their marijuana-certified specialist, and they were going to do it anyhow, and the question was, but they wanted to keep the link open with me anyhow because I was maybe the safer person to talk to about this, and you have to make this very tough decision. Yeah. Okay, it's better that I know about it than that they not come back. Yes, very important. So lastly, I wanna leave you with another couple of mentors. So Leston Havens, who is really a giant in our field, and I got to see him speak on two occasions, and his daughter Jenny now is the chair at NYU Child Studies. He gave us the three psychologic analgesics. So when we were growing up, it was take two aspirin and call me in the morning. When we were on call, we know we can't do aspirin, but we could do Tylenol, take two Tylenol, and wake me up in four hours and the fever come down. The concept of the analgesic is that we want to first protect self-esteem for our patients and families. It's safe to assume that by the time they come to us as child and adolescent psychiatrists or as general psychiatrists, their self-esteem has been potentially affected. They may be highly stigmatized. The parents may feel like they're terrible parents and they cause this by bad genes or bad parenting or some combination. So we ought to help them hold it together in our presence. Now, maybe they wanna cry in front of us, but they don't wanna cry in front of their child. Maybe they all wanna cry together. Maybe nobody wants to cry or really in that first session or two, what they really wanna do is just, the parent wants to show up for their child and try to show that they're doing the right thing. So how do we protect the self-esteem, not only of the child or teen, but also of the parent? Number two is emoting a measure of understanding and acceptance. We got that a little in the cultural section. And if you're successful, you've not only gotten this problem intellectually, you've not only tapped into the parent's explanatory model, especially if they're from an immigrant community, but you've conveyed this idea that you understand this from their point of view. You're not them, but thank you for sharing your story. I have a better understanding of what you're hoping for here. And then last but not least is the idea of providing a sense of future, that by the time they come to us as psychiatrists, especially with their children, they've lost all hope. They feel like we've tried all these medicines and we're frustrated. We had to wait six months to get this appointment. We're paying out of pocket. Like you have to kind of know what this family's had to go through, not to mention the parking to get to our place. But you know, we can acknowledge their sense of frustration and hopelessness, but we can use a little trick that Havens recommends, and that is the use of the term for now. It may seem really frustrating right now. It may seem hopeless for now, but then you have your opening. I think we can do some good work together. I think there are some good options here for medicine. And so remember, we don't do this work alone. Those of you who are just about to graduate, you are gonna be allured by these very high paying jobs that offer you twice the salary of your full professor faculty to just push pills. That's not why any of you signed up for this gig in medical school. Work interprofessionally. Empower the eyes of the educators to be your clinician out of the office. The other therapists, the parents, obviously, the primary care clinicians, read voraciously about the conditions that your patients come in with and about their side effects. Don't just assume you've been doing it for five or 10 years, you know everything about it. The more patients you see, the more new stuff you'll learn about how stuff presents. Visit the websites that your patients and parents are going to. You'd be surprised, there's a lot of good stuff out there. There's also a lot of trash. But I think there's more good now than there was when we were working together, Carl, in the first days of the interweb. And be mindful, and this comes from Leston Havens, that getting better may actually be scary to a patient and a family who may be very used to a certain kind of pattern and a certain kind of response to a certain kind of whatever it is, behavioral approach or medicine. But Havens wrote in the early days of phenothiazines, when patients with psychosis who would be institutionalized for years, and the dramatic changes that medicine, modern medicine now brought. And he wrote about his patient who wouldn't take the medicine because she was fearful that the voice of her deceased husband would be gone forever. So making sure we find out what is the hope, what do you hope to get from this medicine? And what are your concerns? Involving the patient, as Carl said, as much as possible in the decision-making process, especially when it comes to teenagers, trying to find out where the parents are with treatment, especially with medicine, especially if they're from a culture that's different than your own. And remembering that the formulation precedes the prescription and not vice versa. We don't go to target symptoms in a presentation right away. When a student or resident's presenting, we ought not to with each other either. The formulation always precedes the prescription. So how we are with our patients is just as important if not what we do with our patients. How quickly we return the messages to the pens we write with, have a drug company name on them. What message are we broadcasting there? What kind of language do we use to explain about mental health and mental illness? And how do we offer realistic hope for the future? And so I'm gonna pause here. We have about eight or nine minutes for a discussion. Thank you for your attention. And we invite you to please raise your hand if you wouldn't mind coming to the microphone just because this is being recorded. That would be wonderful. Please tell us your name and where you come from. Hi, thank you. My name's Nick. I'm an outpatient child psychiatrist in Montana. I'm curious and maybe this is like what would you do type of question. Strategies to facilitate alliance in this current climate of divisiveness, anti-trans, undemocratic, bills rhetoric. Yeah. We have a wonderful, thank you Nick. We have a wonderful opportunity together right now to think about this because we are a collective in this room of 30 or so people who've remained for the entire hour and a half. And I'm curious about what other people's experiences are. I can share that in our fellowship we have one John Updike, put a pin in that name. He's a community track fellow in our fellowship. We have one of the only community tracks in the country and he engages a lot with minoritized communities but he comes from Wyoming. And he is being asked to run for state assembly when he goes back because he is a great joiner. He's a great convener. He is able to put up his ideas about things and his strong advocacy for things like gender affirming care in a place that really doesn't have a lot of people who believe in that. But again, opening the door to a conversation allows you to understand what people's hangups are. Is there something we can all get behind? In Texas where I spent 10 years, yes indeed I did spend, I did 10 years in Texas. We couldn't get anything passed in the way of gun legislation. But we did get money for mental health, a lot of money for mental health. And so now they're opening the largest triple board program in the country. UT Southwestern's gonna have five spots. That's like twice or three times as big as any of the rest of us because the state is putting their money behind mental health. Who would have thunk it? But that's kind of a silver lining out of some tragedies. There've been mass shootings. There've been all kinds of, so I think it's about if you're the person who feels like, okay, I'm gonna plug my nose, but I'm gonna sort of dive into what are the politics of this. Is there someone who's sitting in a position of power in the state capitol who might care about some aspect of what I do here that might get them to lean in a little bit? That's a very broad answer, but that's what I've learned from John who comes from Wyoming, who has dealt with something similar. People ask him, why would you go back there to deal with just the stuff you're talking about in places like Montana or Florida or name the state that's not California. It does take not working alone, figuring out what's important to this legislator. What's gonna make him look good? Do any of you know who Stephen Taylor is? Steve Taylor is from Alabama. He was one of the first cohorts of Triple Board. Tammy Benton, who is our incoming president for ACAP, she was a fifth year when I was a first year at Einstein, and her cohort was Steve Taylor. He does a lot of work in addiction and addiction prevention. She just shared the story. They were speaking in front of the Senate, the federal, our Senate, body of 50, and the senator from Alabama who normally would never have a kind thing to say about a person of color trying to represent some really important new intervention based on his previous comments. But he got up there and he was celebrating the hell out of Steve Taylor, Dr. Steve Taylor, because Alabama was doing some really important interventions as related to opioid addiction, and he was proud that they were getting some of this money and that Dr. Steve Taylor from Alabama was gonna be helping deliver these treatments. Well, you know, that makes him look good because his state is doing something that other states aren't doing. Do others have ideas about that? Anything you've learned in your communities? I have one comment to make about that, although I think yours is the best. This is just a little one besides that. My experience is that there's a lot of stigma and fear and prejudice about psychiatry and all these associated issues that you've mentioned that aren't even associated issues, really. But there is a potential sometimes for an alliance if you can show results. I mean, these state legislators, they have kids too, and they know people who have kids who have problems, who've taken overdoses and all kinds of things. And if you can promote measurement-based care, and not just have contact with this very suspicious type of professional called a psychiatrist, but you actually have patients reporting good outcomes that are measured, I think there is some potential for working in that environment. Thank you for fighting the good fight, Nick. I think we have time for one more question or comment. And someone is coming up to the microphone right now. Hello. Hi, I'm Michelle. I'm a child psychiatrist at Seattle Children's. All right, Michelle, at Seattle. Yes. Okay. So in Washington, our age of consent for mental health is 13, and I was kind of curious to hear what your thoughts are about navigating that, because it is potentially possible for a parent to have zero input in a child to reuse the parent out. So I'm kind of curious, taking all these thoughts and ideas that you've been discussing, what do you recommend in that situation? So the age of consent is 13 in Washington for mental health. It's 12 in California. And your question relates to what happens if they're seeking care because of the parents, or in spite of the parents, how do you bring parents in? How do you navigate that? Great question. So you may know, or maybe you don't know, but if you don't know, you heard it here first, Alcove, Alcove for all of us, A-L-L-C-O-V-E, look them up, alcove.org. It's based on the Australian Headspace model, not Headspace the app. It is a wonderful app, but this is the Headspace drop-in mental health centers around Australia, where young people can go to get their own care, not only for mental health, but for primary care, if there is food insecurity, if there is job training. And we are beginning to open those in California. And this issue comes up. So we don't want being able to walk in the front door without a parent to be a barrier. And that's the reason why you have such a young age of consent to seek your own treatment. But I think it would be foolish for us to assume that we can make meaningful difference without involving a parent in the immediate, if not in the immediate short term, at least within the first few weeks, at least letting them know, asking your patient's permission to let them know that this, you know, your child is requesting treatment. And, you know, we want to find out more about your experience, were you aware. Now, you work with the patient in that case, you know, and saying, I think, you know, by session five or six, we ought to really think about involving your parent. But it is tricky, because what we see in some school mental health sites is, because of FERPA and because of the mandate to be sure that the parent is involved because the school district is paying for those school-based services, there is a mandate, you cannot come see me unless it's a crisis, but you can't come for ongoing school-based treatment unless your parent signs permission. This is exactly why you have a younger age of consent in Washington and us in California. So I think it's important, because it reduces the barrier to seek care and begin care, but then once you're in care, and it might be any of you who is working in one of these centers, it's important to know who are the trusted people in that young person's life. You know, if you do a circle of care exercise or a circle of trust, or as you might do in interpersonal therapy, do an interpersonal inventory, or just a genogram where, you know, I teach an undergraduate course on special topics in adolescent mental health. In the very first week, we talked about the genogram. Why do we do a genogram in child and adolescent health? We wanna know who the people are. Who's gonna show up for this person? Well, maybe they identify a coach or their primary care doctor or a clergy person. Maybe that person has the conversation with the parent if they don't feel comfortable with you. But at some point, we have to engage whatever custodial adult is at home to try and generalize the things that we talk about in this session. But I think, initially, it's really important. If we can make that age of consent younger, and if we have a young person experiencing a barrier to come in, but then a young person can come in because they don't need their parent consent, that can be an extraordinary opportunity as long as we pay attention to, well, who are the other people we need to engage at some point? Do you have any thoughts on that? No, I think this is such an important question. We know about all the controversy about what's happening, fighting the schools who might be dealing with genderqueer kids who come out in school and the parents don't know. We need a special colloquium just to try to come up with strategies for how to engage parents in a more productive way than just we have now. Yeah, and the age of consent has to do with therapy. So if it relates to medicine, it's 16 and above in most states. But relating to seeking mental health care, mental health support, certainly you're talking to someone who believes that it should be 12 and above, 13's pretty good. We learn a lot from Washington, actually, in California. Some of our suicide prevention legislation was really adapted from what Washington first developed. So good on you for working in a place that's making good changes. Thank you. Thank you. Well, we are at 3.05 Pacific. Thank you, everyone, for staying late. Thank you for your comments. And enjoy the rest of the meeting. Enjoy San Francisco. Thank you.

psychopharmacology

relational principles

psychiatric care

therapeutic alliance

diverse youth

cultural competence

implicit biases

motivational interviewing

integrative treatments

Y model

patient adherence

family psychology

adolescent consent