S24 Ep9: Adolescent Mental Health with Dr. Stephanie Hartselle, MD

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Speaker 9 Something Was Wrong is intended for mature audiences and discusses upsetting topics. Season 24 survivors discuss violence that they endured as children, which may be triggering for some listeners.

Speaker 9 As always, please consume with care. For a full content warning, sources, and resources for each episode, please visit the episode notes.

Speaker 9 Opinions shared by the guests of the show are their own and do not necessarily represent the views of broken psycho media. All persons are considered innocent until proven guilty in a court of law.

Speaker 9 Responses to allegations from individual institutions are included within the season.

Speaker 9 Something was wrong, and any linked materials should not be misconstrued as a substitution for legal or medical advice. I'm Tiffany Reese, and this is Something Was Wrong.

Speaker 8 My name is Dr. Stephanie Hartzall.
I am a physician and a psychiatrist and board-certified in both pediatric and adult psychiatry.

Speaker 8 I teach at Brown University, the medical students about anything from psychotherapy to neuroscience and cognitive circuits.

Speaker 8 I also am a spokesperson for the American Academy of Child Adolescent Psychiatry in the media speaking on a variety of topics.

Speaker 8 I was born and raised in Northern California and moved up to Oregon for college and always wanted to be a doctor but thought I was too bad at science.

Speaker 8 When I got up to Oregon, I became an EMT and realized that I really wanted to be a physician.

Speaker 8 In Oregon I lived out in the rural section of central and then eastern Oregon, which happened to be one of the locations of many of the wilderness programs we're going to be speaking about today.

Speaker 8 When I lived in Bend, Oregon, and I was an EMT in the late 90s, early 2000s, there were numerous programs out there in eastern Oregon. And I would see people coming in emaciated.

Speaker 8 I would see them with severe injuries, bobcat bites. all kinds of things.
These kids coming out who've been kidnapped out of their beds in the middle of the night and taken to these programs.

Speaker 8 And I remember asking the physicians, how are these programs running? And the physicians would say that they get shut down and restart under a different name.

Speaker 8 It's a horrifying aspect of unregulated things that are called mental health treatment that are not.

Speaker 8 Then I went to medical school at Northwestern in Chicago, came to NYU Bellevue for my adult residency and ended up at Brown University for my child psychiatry. fellowship.

Speaker 8 I also run a private practice here in Rhode Island. We have six physicians and we're licensed in multiple states.

Speaker 8 My passion is making sure that the media portrays children, adolescents, and adults in an accurate, healthy way in movies, streaming, shows, podcasts. And so I'm very happy to be here.

Speaker 10 Your education and your background is extremely impressive. And considering the topic at hand, we were so grateful that you agreed to give us some of your time.

Speaker 10 In the industry, when you're talking to other experts, what is the general opinion of these types of programs from credible sources, people who are science-based, trauma-informed doctors?

Speaker 8 I can't speak for everyone, but when we hear about wilderness programs, all of our internal anxiety flags go way up.

Speaker 8 Because for 20, 30 years, there have been cycles of these programs coming in and out that have been unregulated.

Speaker 8 Understandably, parents who are scared and at their wits end will agree to these programs.

Speaker 8 There are, I think, several in the United States that run things according to what should be done and are certified by national organizations who check in with them and they have clinicians running them.

Speaker 8 But most of the time when we hear parents talking about sending their children to a wilderness program, we are very, very anxious as providers because we know that the vast majority can be incredibly damaging.

Speaker 10 That's what's so shocking to me. How do you feel like these systems are also getting the cosign from some of these licensed individuals?

Speaker 8 It's a good question.

Speaker 8 I think sometimes coming out of training and your first or second jobs, when you have an individual running the organization and is a powerful presence and letting you know that this works, these are our results and this is how we do things.

Speaker 8 You can get a little I don't want to use a common term, but brainwashed.

Speaker 8 If you are surrounded by people who also believe that this is the right way, it's an echo chamber and it's hard to see what might be really happening.

Speaker 8 And it can really fuel the trauma that happens even for licensed individuals who are in these programs treating patients.

Speaker 10 We're seeing in a lot of these programs and institutions, survivors shared that there was a lot of religious influence and expectation.

Speaker 10 In your opinion, does that sometimes influence professionals' involvement in these if they have a personal tie to a cause or a religion like that?

Speaker 8 I think it can, not to to say that every organization that has any kind of religious situation is like this, but I think that echo chamber can create something where you do not hear any disparate opinions and really doesn't take into account the fact that the child may not be responding to or buying into at the beginning.

Speaker 8 And maybe the trauma comes when this gets integrated into their minds as they're trying to get out and get healthier. Be very aware of what is the philosophy behind the program.

Speaker 8 What kind of values do they promote? Where are those coming from?

Speaker 10 Absolutely. In your experience, what are some of the more commonly overlooked warning signs in adolescents, children, teens that are struggling with their mental health?

Speaker 8 It's tricky because there is, of course, natural changes that happen as teenagers grow. They're supposed to start individuating.
They're supposed to start disagreeing.

Speaker 8 It makes it easier for them to launch out of the home. So you will see mood fluctuations.
You'll see oppositional behavior.

Speaker 8 And things that I watch for are pretty dramatic changes, a significant withdrawal into themselves. They're no longer participating in family events.

Speaker 8 And this is not just like, you know, oh, family is embarrassing and I don't really want to do that. This is a complete withdrawal.
They're not participating in sports. Their social lives have changed.

Speaker 8 Their friend group. has changed dramatically.
One of the things I want parents to know about is that shame never works.

Speaker 8 And for parents who are noticing perhaps a really dramatic change in functionality to be curious about what's going on, asking them like, oh, tell me about your new friend group without pushing too hard.

Speaker 8 But in teens, and especially those who identify as male, often depression can come out as anger and oppositionality and to really be aware of that.

Speaker 10 A lot of the stories that we've heard both from parents and survivors of these programs is that the parents were scared.

Speaker 10 They were seeing in their teen, maybe some drug use, sometimes stuff as small as what they were wearing.

Speaker 10 Is there a way for parents or caregivers to distinguish between what's typical teenage behavior? What other resources could people be bringing in besides these programs?

Speaker 8 Navigating the mental health landscape and knowing what to do is truly a nightmare.

Speaker 8 One of the things that I do recommend to parents is to find websites that have vetted clinicians on them so that they can find someone by insurance, by client, age, and all these things and know that there has been a clinician on the other end who's talked to them and knows that they adhere to the science.

Speaker 8 There are some wonderful websites that do connect people to reliable programs or help that they can find. I think reaching out to evidence-based folks is one of the best ways that they can go.

Speaker 8 Their pediatrician is also a wonderful resource. Pediatricians manage all kinds of things like this.
They're really the front line in terms of psychiatry.

Speaker 8 And often parents are embarrassed or they just don't realize the pediatrician is a fantastic resource.

Speaker 8 Asking the pediatrician, what resources do you trust in the community or online that we could reach out to?

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Speaker 10 What are some common misconceptions about psychiatric care, mental health, when it comes to youth that stands out to you as somebody who works day in and day out in this topic?

Speaker 8 I think there are contributors certainly through social media, but one of the things that we don't, I think, emphasize as much to parents is that The brain is an organ.

Speaker 8 There are factors that influence things like seizure disorders and make them more or less likely to have seizures.

Speaker 8 But we think about the brain and mental illness with much more willpower and an ability to white knuckle things than we would asthma or migraines.

Speaker 8 So to have parents and caregivers really think about the fact that this is still medical. Psychiatry and medical illness, they are not under different umbrellas.

Speaker 8 And because we have autonomy and choice, I think often parents believe that children are doing this on purpose or not trying hard enough and to instead think about the idea that if they are reaching out for help or they're talking about suicide or they're cutting, to try to think about what if your child was laying in bed and had an asthma attack and wasn't breathing well, would you tell them to just try harder or would you reach out to your medical doctor and get some help for that?

Speaker 8 I think it also helps parents not feel so guilty about the idea that I'm doing something to make this child feel this way or do these things.

Speaker 8 The brain is an organ and we have to also consider that fact as well.

Speaker 10 Something that has definitely stood out to me as I've been going through the interviews and doing research is how many of the survivors we've spoken to that were some diagnosed at the time, many undiagnosed neurodivergence, so ADHD, autism, et cetera, especially for women.

Speaker 10 How are we missing diagnosis and how are we improving diagnosis for neurodivergent individuals?

Speaker 8 The rates right now are that boys and men are diagnosed at four times the rate that women are and that that's the epidemiology of it, but I don't believe that to be true.

Speaker 8 I think that many, many women are missed. Even in my own practice, I've been open for 11 years and have many patients that have stayed with me for that entire time.

Speaker 8 I learn more and more about how autism and that spectrum presents in women, having more conversations about the idea that I think this is going on and I think I missed it.

Speaker 8 In families, autism is hereditary. It doesn't mean that everyone has autism.

Speaker 8 Sometimes there are families where there is a parent and a child with autism and it might be a different flavor and so there could be extreme conflict because of that.

Speaker 8 Sometimes a child has autism and the rest of the family is not neurodiverse in that way. Their brains are special and have so many different amazing abilities.

Speaker 8 But the way that they take information in and sometimes produce information as they process what's going on can be read as aggressive, terse, uncaring, or flat.

Speaker 8 I think it's an important issue for parents to know that if your child seems to really struggle socially, they approach things in a very different way and have an incredibly unique brain.

Speaker 8 The communication between families and that child might be really, really frustrating. And sometimes pediatricians and psychiatrists have very rigid ideas about what the spectrum looks like.

Speaker 8 Many of us at the forefront are now understanding that there is not an incredibly high bar to call autism.

Speaker 8 I'm not saying that everything on social media indicates that someone might have neurodivergence, but I think we miss women frequently because it presents differently and we have not focused on them.

Speaker 8 One of the first things that I realized was the deep and often functionally impairing empathy that can happen.

Speaker 8 Those who are on the spectrum tend to have more gender diversity and awareness of gender flow than folks who are not on the spectrum. And so that's very important as well.

Speaker 8 But truly, this deep and impairing empathy that can manifest as extreme anxiety and paralysis is one thing that I think we've missed and is frequently present in women.

Speaker 10 In today's landscape, in the United States, where we don't have socialized medicine or we don't necessarily have equality and access to care, healthcare deserts, things like that.

Speaker 10 How does it influence our culture?

Speaker 8 I can't speak for all physicians, but those of us who are mid-career and younger, I would say the vast majority of us wish desperately for universal health care and a single-payer system.

Speaker 8 Our system divides also medical care and psychiatric care into two different funnels and do not treat it equally. Even when people have health insurance, they have enormous deductibles.

Speaker 8 They can't find people who take insurance, me being one of them. And so the illness just gets worse and worse.
Our system is unfortunately incredibly broken.

Speaker 8 I do believe that the insurance carriers do not have patient care in mind. I think that they are out to make money.

Speaker 8 When patients submit for reimbursement in my practice, I tell them how to do it because it gets kicked back like three times for no reason.

Speaker 8 I think there's a policy to hope for attrition so that they don't have to pay out. I am enraged by our insurance system.

Speaker 8 And we as a practice constantly talk about how we can continue to help bring health care to people who do not have access to it.

Speaker 8 But being individuals, we have to think on a larger scale and it's a tricky problem to solve.

Speaker 10 How can we help folks determine legitimate mental health options?

Speaker 8 There's a website called Cereal for Dinner. It's a peer collaborative, but led by someone who's very knowledgeable and has science experience and degrees.

Speaker 8 They have put together this resource that helps with functionality, but there's also a section of accessing low-cost and free vetted health care systems.

Speaker 8 The leader of the state continues to accumulate resources. I continue to look for resources where I can send families to find vetted and verified programs.

Speaker 8 But it's one of the reasons I think that wilderness therapy and other kinds of unregulated programs blossom. People are understandably at their wits end.

Speaker 10 What are some red flags that you would caution people, especially parents or caregivers, to consider if they are looking into these kinds of programs?

Speaker 8 First step: there should be an assessment of the child and the family by a licensed clinician before there would even be an admission to the program.

Speaker 8 The family should be able to visit the program if they needed to before the child went and look and see where are the areas that children are taken, what are the programmatics, who are the clinicians, how are they licensed, what state board do they report to, who inspects them.

Speaker 8 If there are demands or even requests that they sign over parental rights or temporary custody to a program. Absolutely not.

Speaker 8 If a child is forbidden from calling home or being able to communicate with the family for any period of time, absolutely not. These programs need to be led by licensed clinicians.

Speaker 8 What happens with medication? What kind of license and training and ongoing training do the providers have?

Speaker 8 What is the situation for medical emergencies, environmental emergencies, storms if they're out in the wilderness. What's the hygiene situation for those who menstruate?

Speaker 8 What is the privacy situation for restrooms, sleeping, for those who are gender diverse? Does the program have philosophies? What are their values? Are there religious ties?

Speaker 8 Are they open to and supportive of the idea of individuality, gender, fluidity, and things like this? Also, just your parent gut.

Speaker 8 Even if all this stuff is checking out and your parent gut says that this doesn't feel right, don't do it. There should not be a high-pressure sales for someone to go into these programs.

Speaker 8 Your gut means a lot as a parent. You know things the best.
You've known your child forever.

Speaker 10 How does prolonged stress or shame that is often used in these abusive institutions or programs impact a young person's mental health long term?

Speaker 8 For many of these kids coming in, it is not often just pure depression or pure anxiety. Often they've had trauma of a variety of types.

Speaker 8 And so putting them into a situation where that circuit of trauma that has already been laid down is being reinforced by shame, by punishment, by deprivation just continues to add to these circuits that will continue to loop as teens emerge, not always but often from programs that are abusive.

Speaker 8 It takes quite a bit of undoing to reassure them as adults later on that they are not back in that situation and that they are currently safe because our brains will continue to replay that trauma.

Speaker 8 Our brains believe that they're protecting us from something that could happen that happened in the past, but it ends up impairing us in our current lives.

Speaker 8 And so, real damage can be done by deprivation, punishment, shaming, all of these things.

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Speaker 10 When I'm just looking at our country at large, the fact that Synanon was able to have so much influence, and then we have the state coming in and helping fund these things.

Speaker 10 And this theory of attack therapy that came from Synanon that really did seem to influence therapy and how people were approaching this, quote, tough love. How did this happen?

Speaker 10 How did these toxic ideologies seep in this way?

Speaker 8 In looking at the literature and watching these documentaries and reviewing some of the ways that we retrospectively looked at what happened and the surge of these programs, there was a confluence of in the 80s, say-no to drugs, children are out of control, and then this promotion in many ways of a militaristic approach to these kids.

Speaker 8 There were programs and news features on these kids were terrible. Look at them now.
We're scaring them straight. We're bringing them into prisons or we're bringing them to these programs.

Speaker 8 There are cultural waves that initiate things. And I think in the 80s, we had a lot of scares about all kinds of things that were misunderstood.

Speaker 8 And I think the political environment pushed things into a very, we are going to beat you into submission and then quote unquote rebuild you and then get you out and put you back in the same environment, have no contact with your family, have no healing that happens.

Speaker 8 And then you will continue to carry those values forward.

Speaker 8 I'm deeply concerned and have been since 2016 about the way that things are going in terms of intolerance and what's happening in this country.

Speaker 8 You referenced therapists and all of us trying to deal with this. Some of the advice that I often give when people are overwhelmed by the news and everything that is so depressing is take a break.

Speaker 8 And I want to empathize with the therapists out there who can't because every hour we get updated on the news.

Speaker 8 Because, of course, our patients are distressed by something brand new that is terrifying that is happening to them or to their families or people they care about.

Speaker 8 And so, sending strengths to folks who are trying to do this work well and who continue to be re-traumatized by what's happening to our patients and fear for what's happening to our communities.

Speaker 8 It's really tough.

Speaker 10 Absolutely.

Speaker 10 These tactics that we've heard used with survivors in the abusive institutions, such as being isolated, restrained, denied sleep, denied food, access to hygiene, privacy when going to the bathroom, et cetera.

Speaker 10 Are any of these methods actually effective in positively changing behavior?

Speaker 8 It works in the way that you can tear people down and they will obey if their survival depends on it. But what does it look like afterward? What are their outcomes measures?

Speaker 8 If it worked, we would have it in our prisons and we don't? And we do it to children in these programs? How is that possible?

Speaker 10 You've won multiple teaching awards at Brown. Congratulations.

Speaker 10 How do you approach educating the next generation of mental health professionals when you're talking to them about working in ethical environments, providing compassionate care for youth?

Speaker 8 We work in this practice on emphasizing strengths and positivity and working with understanding outbursts and behaviors through a lens of empathy.

Speaker 8 Also, limits and structure, when provided that are reasonable and with love, do bind anxiety and help children feel safer.

Speaker 8 And what I mean by that is when you have a chaotic household and understandably parents are trying to survive and all these things and there are no rules or the rules are intermittently enforced, anxiety and depression can really run rampant and produce behaviors in children that are oppositional or disturbing.

Speaker 8 We do work with parents around the idea that firm but caring limits with explanations are important so that children feel safe, but torture and punishment, that's a very different beast that we don't encourage at all.

Speaker 8 One of the main things that I talk about is shame. And as a physician, making sure that you are working with all of your strength on not shaming patients.
Don't shame them with your face.

Speaker 8 Don't shame them with your tone of voice. Don't shame them with the reason that you think that they're coming in.
Patients are already ashamed. They don't know if they're going to be listened to.

Speaker 8 If they are folks of color or in the gender spectrum or LGBTQIA population, they are used to being dismissed, ignored, called hysterical.

Speaker 8 Practice with colleagues, see what you look like in the mirror. It is one of the most important parts about connecting with patients and being able to treat them, diagnose them, and help them.

Speaker 10 We talk a lot about the media, not only on Something Was Wrong, but also on our sister show, What Came Next, which specifically focuses more on media impact on survivors and the public's response to crime and how that then also continues to impact their lives and trajectory.

Speaker 10 I would love to hear from you in what ways you've seen media be positive for survivors of domestic violence or the program or this is Paris, because we've heard a lot of positivity from survivors this season.

Speaker 10 That was the first time they felt understood.

Speaker 8 I love that Paris Hilton came out and spoke on this.

Speaker 8 I thought it was so impactful that survivors could see someone who from the outside seemingly had it all and maybe had some rough years, but really explained what happened to her.

Speaker 8 In my patient population and folks that I talked to, it changed lives. dramatically.
And I think that media can be incredibly supportive.

Speaker 8 There's going to be a paper coming out soon on boys and media that I co-authored with two other amazing folks. We talked about in the research what areas social media does provide positive aspects.

Speaker 8 There are algorithms that people go down that really help them understand that they're not alone. They might be in a remote area of the country with no one else who is like them.

Speaker 8 They've been through these experiences and they can find other survivors who are giving them tips on how to continue in their day, how to find work that is understanding if they need mental health breaks and things like this.

Speaker 8 I sat and watched a documentary called The Mask You Live In. I watched it with my 16 and a half year old son.

Speaker 8 It talks about a lot of things that I think even as a psychiatrist after 23 years, I wasn't aware of.

Speaker 8 It was a lot about competition, the pressure for boys and the isolation and the lack of emotional connection that happens, especially after puberty. And we paused and I looked at my son.

Speaker 8 He's a very emotionally in touch kid. And I said, is this what goes on sometimes in your brain? He said, this is what always goes on in my brain.
This is everything that happens to boys.

Speaker 8 And I was devastated and floored. In many ways, we've had attention on girls and how the environment has traumatized and shaped all of us.

Speaker 8 We need to also now focus our attention on the boys who've been left behind. They are alone.
They are isolated. They have no outlet.

Speaker 8 Their entire world is competition and feeling often like they are failing. And I think it drives and pushes some of the cycle of violence that we are trying to fight against.

Speaker 8 I'm on a volunteer committee that puts out a great resource called Facts for Families. It's a one or two page document that talks about teen depression.
What does it look like? How do I access care?

Speaker 8 What questions do I ask? when my child is going into the hospital, what rights do I have? It's free. It's called Facts for Families.
You just Google that. You can find a number of amazing resources.

Speaker 8 But one of the things we're going to talk about next is going to be about boys' emotionality and pornography and how it impacts children and teens.

Speaker 10 Such important work. Brene Brown, I read a book of hers about doing shame research and how men had been negatively impacted.
Their number one fear was often reported to be being seen as weak.

Speaker 10 how toxic masculinity really hurts men. Of course, it hurts women, but it also hurts men.

Speaker 8 In my practice, we talk about what is your algorithm. One of the questions I like to ask people is, who does TikTok think you are?

Speaker 8 We talk about how to adjust their algorithm so it's supportive to them and they can connect with other people who help them through this experience.

Speaker 8 I am so thrilled that people are coming out and speaking about this, those in public, that you never would have thought maybe went through these experiences.

Speaker 10 For those who are listening who are unhoused or do not have health insurance, are there any resources or ways that you feel like they could try to advocate for themselves to try and access mental health resources?

Speaker 8 It's a tough question. There are hospital systems that take care of all.
I worked at Bellevue Hospital in New York. For those who aren't on the East Coast, it is a hospital that takes all-comers.

Speaker 8 Anyone who even floats ashore in an inner tube from another country. In Portland, Oregon, a manual hospital is one of the first places that I started working.

Speaker 8 There are hotlines run run out of some of these community hospitals that serve all-comers.

Speaker 8 I can't say how the landscape might change in the next few years, but for those who are unhoused, 988 will connect folks to help.

Speaker 8 It is the number that people call for psychiatric emergencies, but it can also help people connect to resources. And so it is very difficult when you are unhoused.
and possibly here undocumented.

Speaker 8 We don't have a system that is accessible to folks who don't have those resources.

Speaker 8 The idea that even just small movements can help and trigger those positive circuits, watching your algorithm and changing it a little bit and looking for, I need a community to support X, Y, or Z, looking through those videos and making connections, even just commenting on videos that have helped them is service and does lead to more positive connections.

Speaker 8 Things can get siloed and certainly things can go in very different directions for folks who are down into algorithms that promote toxicity in all kinds of ways.

Speaker 8 This generation of children and teens, I think, have such an impressive amount of empathy for each other, an ability to accept and easily flow with preferred pronouns and all of these things.

Speaker 8 I do have hope that this generation, in many ways, is going to be so different from mine, so different from yours. I'm very encouraged by that.

Speaker 10 Absolutely. A lot of it has to do with our teachers and how much they are adding value to our children's lives.
They are teaching more emotional intelligence. There is a lot of positive things too.

Speaker 10 So I'm happy we're ending on a positive note, even though the topics obviously can be very bleak. I appreciate you again so much for your time, your willingness.

Speaker 10 Is there a specific website or one place if somebody was going to go where we would direct them to?

Speaker 8 The American Academy of Child and Adolescent Psychiatry. There are medication guides there.
There are resource centers there available to the public.

Speaker 8 I think those places can give a lot of information that will help families.

Speaker 8 And I'll also link one pager on important questions to ask about any treatment program so that families have those with them.

Speaker 10 Amazing. And we'll certainly link to your personal pages that you provide.
Thank you again so much for your time.

Speaker 8 Thank you for having me. I really appreciate those this important topics.

Speaker 9 Something Was Wrong is a broken cycle media production. Created and produced by executive producer Tiffany Reese, associate producers Amy B.

Speaker 9 Chesler and Lily Rowe, with audio editing and music design by Becca High.

Speaker 9 Thank you to our extended team, Lauren Barkman, our social media marketing manager, Sarah Stewart, our graphic artist, and Marissen Travis from WME.

Speaker 9 Thank you endlessly to every survivor who has ever trusted us with their stories. And thank you, each and every listener, for making our show possible with your support and listenership.

Speaker 9 In the episode notes, you'll always find episode-specific content warnings, sources, and resources. Thank you so much for your support.
Until next time, stay safe, friends.