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Complicated Grief: How to Cope with Loss in Complex Situations

“How lucky I am to have something that makes saying goodbye so hard.” — A. A. Milne, author of the “Winnie-the-Pooh” children’s books

For better or worse, loss is an unavoidable part of life. Loss can come in many forms, such as the death of a loved one, a life-altering injury or medical diagnosis, the breaking-up of a family, the termination of a friendship or romantic relationship, or even the untimely end of a job or career. A loss can be large, small or somewhere in between, and it can affect us in a wide variety of ways.

Grief is one common and very normal reaction to loss. In its simplest sense, grief is deep sorrow or distress that we feel because of a loss. Grief is our natural response to the loss of something that was familiar or comforting to us, and grieving is our way of coming to terms with that loss. The grieving process could take days, weeks, months or even longer, but it usually ends with acceptance and a return to relative peace.

However, grief can sometimes be so intense that it does not go away on its own. Rather than diminishing over time, feelings of grief may sometimes remain unchanged or even get worse as the loss fades into the past. This type of persistent, unresolved grief is known as “complicated grief,” and it can severely impact a person’s mental health and their ability to live a normal life after experiencing loss.

In order to heal from complicated grief if and when it occurs, it’s important that we understand what it is and how it affects us. In this blog post, Cummins school-based therapist April Allgood explains how complicated grief differs from regular grief, what types of loss may cause a person to experience complicated grief, and how someone who is suffering from complicated grief can begin to heal from their loss.

Layers of Loss, Layers of Grief

April Allgood, MSW, LSW, School-based Therapist at Cummins Behavioral Health
"Especially over the past few years, I've really had to become comfortable with grief, because about two-thirds of my caseload deals with complicated grief," says April Allgood, MSW, LSW, a school-based therapist at our Boone County office. April works with school-aged youth and their family members in her day-to-day work.

As mentioned above, the first major difference between regular grief and complicated grief is that regular grief goes away while complicated grief does not. “Typically, individuals are able to adapt to a new normal and learn how to move on,” April explains, “but with complicated grief, symptoms are persistent. They don’t go away, and they impair the person from moving on to what life was like before the loss.”

Just as everyone experiences grief in their own way, complicated grief doesn’t present itself the same way from person to person. In general, though, it is typically characterized by extreme, seemingly unbearable feelings of sadness, guilt or hopelessness. A person is also more likely to experience complicated grief if they’ve suffered multiple losses at the same time or if their grief has multiple layers.

April offers a few examples:

“Especially with COVID-19, there are individuals who are not able to be at their loved one’s bedside to have that final goodbye, or maybe they can’t have the typical funeral or celebration of life. That puts those individuals at a higher risk for complicated grief, because they’re not able to mourn the loss of their loved one in the way they normally would. Another example is when a child is removed from their home. For parents, having their child removed is very tragic and very hard, but sometimes they also have to come to the realization that their choices resulted in their child’s removal. Or maybe one parent is struggling with the loss of their child, so they may potentially resort to substance use, and then maybe they are incarcerated. For the remaining parent, not only was their child removed, but their spouse was then incarcerated for substance use, so they might experience complicated grief because they lost two big entities of their life and their support system.”

Another common difficulty of complicated grief is that each layer of grief can distract from the others, effectively prolonging the overall process of grieving and healing from loss. “Say it’s that parent—when they’re managing the emotion connected to their spouse going to jail, it takes their focus off of grieving their child’s removal from the home,” April says. “It creates a deeper layer because there’s two different things they have to grieve.”

Strategies for Coping with Complicated Grief

Although complicated grief can be an extremely difficult experience, there are many ways a person can cope with their feelings and begin to work toward some sense of resolution. First and foremost, it is always important to reach out to people who can provide emotional support. This support can be found through professional behavioral health services as well as among friends, family members, teachers, coaches, and other individuals who care about our personal well being.

When it comes to professional services, therapists and counselors can help a person make sense of the emotions they are experiencing and understand that their feelings are normal and valid. “It’s my job to help them understand what they’re going through and how it impacts their body, their emotions and their thoughts,” April says. “But I also try to help them comprehend the loss and address the grief. In my office, I try to create a safe, non-judgmental space where that individual can share what’s on their mind and understand that it’s OK to have the emotions they have.”

In addition to seeking support, April stresses the importance of increasing self-care and maintaining regular wellness behaviors like getting plenty of sleep, exercising regularly and eating a healthy diet. Another coping strategy that people sometimes overlook is emotionally preparing for upcoming holidays or anniversaries of their loss. “I help a lot of people of all ages prepare for those moments, because they can be a big shock for families and individuals to go through, especially if they’ve not had to process or deal with that before,” April says.

Professional therapy or counseling can also help the entire family deal with the ramifications of complicated grief, as it frequently affects others who are close to the grieving person. April explains,

“As professionals, we are trained to help not only children, teens and adults navigate this new way of life, but the family as a whole. Grief can be an uncomfortable topic to discuss, but we’re well trained in that area, and it’s not an uncommon topic for us to deal with. Therapists can help caregivers and guardians understand how to talk to their loved one about the loss, and we can also help them come alongside the grieving person to help them develop healthy coping skills and a new way of surviving life without that person who’s potentially gone forever or just gone temporarily.”

Ultimately, the goal for someone who is experiencing complicated grief is not only to move past their loss, but to emerge on the other side stronger than they were before. “I really try to help them understand their resiliency,” April says, “because anyone dealing with a loss is also creating very strong character traits. I try to help them understand that they’re sometimes stronger than they think they are.”

For more resources to help someone build resilience after a loss, we recommend reading our blog posts on gratitude and learned optimism below!

The Power of Being Thankful: Jessica Hynson, Jeremy Haire & Mindy Frazee Explain the Benefits of Gratitude
Training Ourselves to be Optimists: Positive Psychology

Wraparound Services: 360-Degree Support for Youth with Greater Behavioral Health Needs

Although childhood is typically perceived as a time of carefree happiness, children and adolescents can also face many challenges to their mental health.

For starters, many youth contend with difficult home issues like poverty, lack of food, poor family harmony, and even domestic violence. On top of these difficulties, about one in six children in the U.S. must also cope with a developmental disability such as ADHD, autism spectrum disorder, cerebral palsy, or other intellectual and learning disabilities. Finally, about half of all mental disorders start before or during the teenage years, further complicating life for youth who have them.

When a youth’s behavioral health needs are relatively mild or moderate, interventions such as individual therapy or counseling, family therapy, or skills training can be sufficient to help them address whatever challenges they may face. However, sometimes a child or teen needs a greater level of support to account for severe or very complicated behavioral health difficulties. In these cases, “wraparound” services may be the best option.

To learn more about wraparound services and how they fit into a behavioral health continuum of care, we spoke with Lakisha Wren, Wraparound Team Lead for our Hendricks County office. In this blog post, Lakisha explains what wraparound services entail, who might be a good fit to receive them, and how they can help create stability and healing for youth with greater behavioral health needs.

Comprehensive Support for Complex Challenges

Lakisha Wren, Wraparound Team Lead at Cummins Behavioral Health
"We've had a good success rate with our wraparound services here in Hendricks County. We've had a lot of people graduate the program, and we even have some families where the youths have gone on to college," says Lakisha Wren, a Wraparound Team Lead at Cummins Behavioral Health.

Wraparound services (also referred to as “wrap services” or “the wraparound process”) are intensive care programs specialized for the specific needs of each consumer. They comprise the highest level of care provided by community mental health agencies, and they are the last option before a youth is removed from their home for treatment purposes. “We work with youth who are at risk of being placed into residential facilities or acute hospitalization,” Lakisha explains.

In Indiana, wraparound services are funded by the Department of Child Services (DCS) and the FSSA’s Division of Mental Health and Addiction (DMHA), and children between the ages of 6 and 18 are eligible. Because the entire family tends to be involved in situations of this kind, wraparound services may be extended to everyone in the household. “We wrap services around everyone, not just the focus child. The mom, the dad, siblings—everyone can get services under the grant,” Lakisha says.

As the access site for wraparound services in Hendricks County, Lakisha is the first person a family will speak to if they are referred for wrap services. Lakisha’s job is to assess their eligibility and connect them with the appropriate care providers. “I’ll assign a therapist and a life skills specialist, and if they need more intensive services, that’s when I would assign a wrap facilitator,” Lakisha explains. “Then they might also receive habilitation services, respite services, and family support training as well.”

Regardless of the exact services provided, the wraparound process is always guided by four key principles of care:

  • Grounded in an inner strengths perspective: service providers assume that every individual possesses valuable inner strengths that can help them thrive in life if they are developed and applied
  • Family voice and choice: all family members have a say in their care and can choose how they would like services to proceed
  • Strengths-based: service providers aspire to identify each individual’s constructive life skills and nurture their development—not fixate on personal shortcomings
  • Outcomes-based: all services are designed to work toward a positive end result as defined by family members and care providers

How Wraparound Services Create Outcomes for Youth and Families


The overall goal of wraparound services is to address whatever challenges a youth is facing without removing them from their normal home environment. With this in mind, efforts are also made to make services as unobtrusive as possible to a child or teen’s daily life. “A lot of our youth do not work well just with traditional services,” Lakisha explains. “They don’t do well just sitting, discussing their feelings and trying to stay focused for a 45-minute session. So, we try to be very creative and think outside the box with our plan of care.”

This is precisely where non-clinical service providers and interventions shine. “If skills training isn’t working, we might try some fun habitation services,” Lakisha says. “For example, a mentor could meet with the youth out in the community and try to do skills training at a basketball court, or just while walking around the community. I think that’s why a lot of our families benefit from wrap services—we try to be creative and make it fun for them.”

According to Lakisha, the highly individualized nature of wraparound services are another important key to their effectiveness for youth and families:

You may have Johnny who does not do well in a school setting, but we can have a support person at school who can sit next to him, help knock down some of those barriers and underlying needs, and pull the teacher aside and say, ‘Have you tried to do this with him, have you tried to do that?’ We can have a habitation provider help that teacher work with Johnny—explain Johnny’s needs, his care plan, and how the teacher can be creative with Johnny. Or we could have another individual who is struggling with just getting up, going to school and being motivated each day, or has suicidal ideation. We can give that person a mentor who’s there on the weekend to pick them up and take them to peer mentoring groups out in the community, or just sit down with the parents and talk about why it’s important to have crisis plans, help them understand suicidal ideation, and things like that. It’s just about having an individualized plan of care for every youth and family.”

By surrounding a youth with various types and levels of support, wraparound services can effectively treat complex behavioral health issues during childhood and adolescence. Most importantly, their focus on helping the whole family lowers the chances that problems will resurface in the future—and keeps youth in the home and community environments where they are loved and feel most comfortable.

Looking for more information about the types of services provided at Cummins Behavioral Health? You might enjoy our blog posts on employment services and substance use disorder services below!

Employment Services: Helping People with Mental Disabilities Find Rewarding Work
Managing Dual Diagnosis: Cummins’ Tracy Waible on How to Identify and Treat Substance Use with Co-Occurring Disorders

Pride Month 2020: What Does Good Mental Health Care for LGBTQ+ People Look Like?

The LGBTQ+ community (individuals who identify as lesbian, gay, bisexual, transgender, queer, or as another nontraditional gender identity or sexual orientation) has made many great strides in recent years. In 2015, the U.S. Supreme Court made same-sex marriage legal in all states, and earlier this month, it ruled to protect gay, lesbian and transgender people from employment discrimination. Despite these recent achievements, however, many people who identify as LGBTQ+ or are questioning their gender identity or sexual orientation still face serious challenges to their overall well-being.

For example, at least 1 in 4 LGBTQ+ people report experiencing some form of discrimination in their daily lives. Discrimination or fear of discrimination can be especially harmful for youth in this population. According to a 2019 survey conducted by The Trevor Project, 71% of LGBTQ+ youth reported feeling sad or hopeless for at least two weeks in the past year, and 39% of LGBTQ+ youth seriously considered attempting suicide, with more than half of transgender and non-binary youth having seriously considered suicide.

Proper behavioral health care can help LGBTQ+ individuals deal with the challenges of discovering and living out their gender identity and sexual orientation. Unfortunately, this care isn’t always readily available. This is partly because not all behavioral health professionals have access to the training and resources they need to treat this population. “In my experience providing therapy over the last four years, one barrier is a lack of LGBTQ-specific resources for mental health professionals,” says Julie Campbell-Miller, an Intake Specialist and Outpatient Therapist at Cummins Behavioral Health. “Even as a self-identified queer person, treating someone from the other side is much more difficult than I ever imagined.”

This begs the question: what does respectful, effective behavioral health care look like for LGBTQ+ individuals? How can mental health professionals help their clients discover and feel comfortable in identities that other people might not understand or agree with? In this post, Julie Campbell-Miller explains what behavioral health care should look like for people struggling with issues related to their gender identity or sexual orientation.

Placing Control in Clients’ Hands

Julie Campbell-Miller, LCSW, Intake Specialist and Outpatient Therapist at Cummins Behavioral Health
"I identify within the LGBTQ+ community, and I have some lived experience in regards to discrimination and knowing how difficult it is to come out to your loved ones. I think it's extremely important for community mental health centers to be vocal and show that they are a safe place to come and talk about these kinds of things," says Julie Campbell-Miller, LCSW, an Intake Specialist and Outpatient Therapist at our Putnam County office.

When a consumer of behavioral health care is seeking help for problems like depression, anxiety or substance use disorder, it is sometimes appropriate for their therapist or counselor to take close control of their treatment. Mental disorders and illnesses can be very complex, but there are typically clear guidelines for treating them as well as clear goals to work toward. However, this is not the case for someone who is questioning or struggling with their gender identity or sexual orientation.

In many cases, LGBTQ+ individuals may not have a specific behavioral disorder that they are seeking treatment for. Rather, they might simply be looking for someone to talk to. “Most people who are seeking services because of their sexual orientation or gender identity just want somebody who’s empathetic and willing to ask questions and learn more,” Julie says. Instead of assuming they know the solutions to their clients’ problems, providers should strive to learn more about their situation, ask what they would like to get out of therapy or counseling, and then work with them toward that goal.

If a person is seeking help to make sense of their gender identity or sexual orientation, it’s also important that professionals resist the urge to come to a conclusion for them. Questioning one’s gender identity or sexual orientation is a deeply personal and sometimes confusing experience, and the person going through this process must ultimately make their own decisions about who they are. Therapists and counselors should act only as guides and sounding boards for this process, as Julie explains:

“It’s different than your traditional talk therapy. You don’t want to tell them what they are because it’s very specific to an identity, as opposed to something like trauma where you can simply point out the cognitive distortion they might be having. For someone who’s trying to explore their own identity, you want to support them in a way that they can come to it on their own. For example, I might give them some resources to read through as homework, and then the next time they come in, we discuss what they thought about it. This helps them to self-identify as opposed to me saying, ‘Oh, I think you might be pansexual,’ or something like that.”

Building Up the Whole Person

As we’ve suggested, there are many educational resources that can be helpful for someone who is questioning their gender identity or sexual orientation. Part of a care provider’s job should be directing consumers toward these resources when appropriate. “One way providers can help is by exposing consumers to resources such as the Human Rights Campaign, The Trevor Project, and Indiana Youth Group,” Julie explains. “For example, I use HRC a lot because they have a glossary with definitions for various sexual orientations and gender identities.”

Beyond simple education about the many gender identities and sexual orientations a person might have, some tools can even help walk them through the process of questioning their identity. “There’s one workbook I like called The Gender Quest Workbook, and it utilizes cognitive-behavioral therapy techniques specific to LGBTQ+ youth who are on the journey of figuring out how they want to identify,” Julie says.

However, behavioral health professionals should also emphasize that their clients are more than their gender identity and sexual orientation. A person-centered, strengths-based approach to therapy should be used to remind clients that they are worthwhile and valuable regardless of what gender they identify as and who they are attracted to. “Counseling is the perfect opportunity for them to identify all of their great qualities as opposed to the one facet they’re trying to make sense of,” Julie says.

Finally, it’s possible that a person might not fully understand or come to terms with their gender identity and sexual orientation by the end of their treatment. This process often takes many years to complete, and it might not be the primary goal of someone’s therapy or counseling. Care providers should reassure their clients that there is nothing wrong with this, and that they can still live fulfilling lives as they continue to work toward this long-term goal.

“I think it’s important for providers to be upfront that they are not necessarily there to help someone identify who they are. They’re there to address what the person is struggling with,” Julie explains. “If you are questioning, and you happen to come to that conclusion by the time you’re done with therapy, that’s awesome. But my goal is for you to feel confident that even if you don’t have that specific identity, you can still live and be happy while you’re figuring it out, and that it will be OK.”

Cummins Behavioral Health is committed to providing exceptional mental health care to people of all genders, races, ethnicities, creeds and sexual orientations—including those individuals who belong to the LGBTQ+ community. If you would like to speak to a behavioral health professional about struggles related to your gender identity or sexual orientation, we encourage you to give us a call at (888) 714-1927.

Or, if you’d like to learn more about the basics of gender identity and sexual orientation, we recommend starting with our blog post about the five dimensions of gender and sexuality!

LGBTQ Pride 2019: Explaining the Gender Unicorn with Youth MOVE

Drug Free Marion County and Cummins BHS Answer “What Are Friends For?” for Substance Use Stigma

Substance use disorder, also known as addiction, is one of the biggest public health crises affecting Americans today. According to the National Survey on Drug Use and Health, around 20.3 million Americans suffered from a substance use disorder (or SUD) in 2018. This includes an estimated 389,000 Hoosiers aged 12 or older. Indiana has been hit especially hard by the ongoing opioid crisis, ranking 14th for most drug overdose deaths by state in 2017.

Despite the vast number of people afflicted with SUD and the well-established science that explains how addictive substances hijack the brain, there is still a significant amount of stigma surrounding substance use disorder. Unfortunately, this stigma only makes SUD more devastating for those who suffer with it. For instance, consider the story of Matt Baker, one of Cummins’ Peer Recovery Specialists who fought to overcome his own struggle with substance use disorder.

Matt’s Story of Addiction and Recovery

Matt Baker, CRS, CHW, Peer Recovery Specialist at Cummins Behavioral Health
Matt Baker, CRS, CHW, Peer Recovery Specialist at Cummins Behavioral Health

Matt was no stranger to the painful realities of substance use growing up. As a child, addictive substances were a common facet of his home life. “That lifestyle was the norm around my home—substance use and a lot of the things that go in line with it. Domestic violence, involvement with the law, time spent in and out of the jail system and other institutions,” Matt says.

When he was old enough, Matt joined the military and escaped this lifestyle for a time. However, he was medically discharged from the service in 2012 after being injured in combat. Upon returning home, his life quickly took a turn for the worse. “I went right back to what I knew, which was an unhealthy coping skill, and that was substance use. I went down that path—being locked up, losing my freedom. I lost my family, I lost everything that really meant something to me,” Matt says.

As he fell deeper and deeper into addiction, Matt started to believe that he was to blame. He thought there must be something wrong with him that made him act the way he did. “I honestly took that old-school view that it was a moral defect of character,” Matt explains. “I literally thought I was a bad person.”

Matt’s substance use became so severe that he eventually ended up in the hospital because of it. It was while he was admitted to the psychiatric unit of a VA hospital that something remarkable happened. “A guy came in who had his own experience with substance use and mental health issues,” Matt says. “He came and talked to us, and he normalized it. He didn’t treat us as ‘less than.’ I could relate to this man. He had a peace and a calm about him, and I thought, ‘I want some of that in my life.’ “

This experience was a major turning point for Matt. From that moment on, he was committed to recovering from substance use and taking back control of his life.  However, a major hurdle on his journey toward recovery was overcoming the stigma he felt as someone with substance use disorder. “I couldn’t do it until I tore down some of that stigma,” he says.

Breaking Down Substance Use Stigma in Indiana

The Marion County Public Health Department’s “What Are Friends For?” campaign is aimed at reducing the stigma surrounding substance use disorder.

Despite what some people still believe, substance use disorder is not a moral deficiency or weakness of character. Individuals who struggle with substance use are not “bad people.” As its name suggests, SUD is a behavioral health disorder. No one chooses to suffer from it, and those who do have great difficulty changing their thoughts and behaviors. In fact, their situation is not so different from someone who struggles to control the thoughts and behaviors associated with major depressive disorder, borderline personality disorder, or an anxiety disorder.

This is the message that organizations like Marion County Public Health Department (MCPHD) and Drug Free Marion County (DFMC) are working to spread in Indiana. MCPHD’s “What Are Friends For?” advertisements (such as the video above) teach that one of the best ways we can help a friend or family member who’s struggling with addiction is to be understanding and compassionate.

Sometimes a loved one may need help resisting cravings, avoiding overdose or finding treatment for their substance use. But according to Michaelangelo McClendon, Interim Executive Director of Drug Free Marion County, sometimes they only need a friendly ear to share their struggles with:

“Our agency gets calls every day from people struggling with substance use, and sometimes they just need us to listen. And that’s what friends are for. Our friends listen when we’re in pain. Sometimes we’re the listening board that can help guide them through the pain of addiction.”

Michaelangelo McClendon, Interim Executive Director and Prevention Program Director at Drug Free Marion County
Michaelangelo McClendon, Interim Executive Director and Prevention Program Director at Drug Free Marion County

Empathy: The Key to Ending Stigma

Ultimately, being a friend to someone who struggles with substance use means putting ourselves in their shoes. It isn’t enough to understand how addiction works and take pity on those who suffer from it. We must truly empathize and admit that we, too, have our share of struggles in life; we, too, are flawed individuals; and we, too, could have developed the same problems with substance use if we had lived their same life experience.

“We live in an environment where people are afraid to show who they really are. We’re afraid of judgment and afraid of being ridiculed for not being perfect,” McClendon says. “We also have a society that is just now learning that people who are struggling with substance use are not throwaways. Life is hard. We all struggle, and we all have different ways of coping. We have to be honest about who we are as humans and create a much more open environment for people to say, ‘I’m imperfect.’ And that takes community.”

And what about Matt Baker—how did his struggle with substance use disorder end? Fortunately, he is now living successfully in recovery and has made a career out of helping others who struggle with the very same issues he once faced. His story serves as a message of hope for every person who suffers from substance use disorder: despite the odds, recovery is possible.

“It’s amazing what happens in recovery,” Matt says. “The people who come out are completely different from the people who went in. There’s definitely hope, and people do change. People do recover.”

If you or someone you know needs help with substance use and lives in Marion County, we encourage you to visit Drug Free Marion County’s website and MCHD’s What Are Friends For? webpage for resources and assistance finding treatment. You can also call our offices at (888) 714-1927 to discuss if Cummins’ SUD treatment services might be right for you.

If you’d like to learn more about substance use disorder and Cummins’ SUD services, we recommend reading these other posts from our blog!

Managing Dual Diagnosis: Cummins’ Tracy Waible on How to Identify and Treat Substance Use with Co-Occurring Disorders
Observing Alcohol Awareness Month with Cummins’ Erin Flick and Virtual IOT

Cummins Mobile Medical Clinics: At-Home Medication Services for People with Severe Mental Illnesses

Although it may not always seem so, mental illness is very common in the United States. According to the National Institute of Mental Health, nearly 20% of American adults—or 46.6 million people—had a mental illness in 2017. This includes people with a wide variety of behavioral disorders such as anxiety disorders, depression, bipolar disorder, attention deficit disorder, post-traumatic stress disorder, obsessive-compulsive disorder, eating disorders and substance use disorders.

However, a smaller percentage of people have mental health disorders that are highly disruptive to their daily lives. These may be severe cases of the kinds of disorders listed above, or they may be what are known as psychotic disorders, which cause people to experience hallucinations or have beliefs that are disconnected from reality (called “delusions”). About 4.5% of U.S. adults—or 11.2 million people—suffer from severe mental illnesses.

Psychotic disorders and other severe mental illnesses can be very difficult to manage, which is why many people are prescribed medication to help control their symptoms. These medications can greatly increase an individual’s quality of life, but restrictions made necessary by the COVID-19 pandemic have also made it harder for some people with severe mental illnesses to receive their medication doses. Behavioral health care providers have had to innovate in order to continue serving these clients during this difficult time.

At Cummins Behavioral Health, our medical services staff have converted our consumer transportation vans into mobile clinics in order to deliver medications directly to the homes of these high-need individuals. Thanks to these mobile clinics, our consumers with severe mental illnesses have been able to continue receiving the medications that keep them safe and their symptoms under control.

We spoke with Beth Borders, our Medical Services Practice Manager, and Brandy Fergason, one of our Medical Assistants, to learn how the mobile medical clinics are helping consumers continue their regular treatment during the COVID-19 crisis.

How the Mobile Clinics Keep Consumers Safe

Beth Borders, BS, and Brandy Fergason, CMA
Beth Borders, BS, Medical Services Practice Manager (left) and Brandy Fergason, RMA, Medical Assistant (right)

Medication can be helpful for managing a variety of behavioral health conditions when prescribed in conjunction with therapy. At Cummins, our medical services team gets involved when a therapist believes medication could be beneficial for a particular consumer. “If someone is receiving services here with a therapist, they would talk to the therapist about medication, and the therapist would collaborate with a psychiatrist to create a treatment plan,” Beth explains.

Some of Cummins’ consumers—such as those who suffer from schizophrenia, schizoaffective disorder, borderline personality disorder or strong obsessive thoughts—receive antipsychotic medications as part of their treatment. Many of these consumers receive long-acting injections of their medication, and many also utilize Cummins’ transportation services to get to and from their appointments. However, this arrangement has become problematic due to COVID-19, as Brandy explains:

“We are not allowed to transport consumers anymore, so a lot of the people that we were seeing didn’t have a way to get to the office for their injection. Some of these people had to be switched to oral medication, but the issue with that is they may not remember to take oral medication on a continuing basis, which is why they were receiving long-acting antipsychotics in the first place. So, we’re now going out and seeing these people who relied on our transportation as well as people who face higher risk from COVID-19.”

Crucially, the mobile clinic program protects these at-risk consumers from the negative consequences of missing their medication. “If these individuals don’t get their medication, they could be prone to having symptoms,” Beth says. “We want to keep them from having any symptoms, and we want to keep them from having bigger issues like being admitted to the hospital. We want to keep them safe.”

What Happens During a Mobile Clinic Visit

Jeanne Lehman Lopez, BS, RN, and Allyn Smith, CMA
Jeanne Lehman Lopez, BS, RN, Registered Nurse (left) and Allyn Smith, CMA, Medical Assistant (right) are also on the mobile clinic team, typically attending to consumers who live in Marion County.

When a mobile clinic van arrives at a consumer’s home, the first thing that’s done is a precautionary screening for COVID-19. “We take their temperature and screen them right outside the van. Once they pass the screening and are wearing a mask, they can come into the van,” Beth says.

Inside, consumers are greeted by a private, controlled environment where they can receive their treatment. “We’ve made the inside of the vans exactly like what we would have in an outpatient lab, Brandy explains. “We have a place for them to sit down, we have their paperwork, we have all of our instrument trays, syringes and blood collection tubes. We’re able to give them their injection or draw blood right there in the van.”

Beth and Brandy typically handle visits in Hendricks, Putnam and Montgomery Counties, while two other members of the medical services team, Jeanne Lehman Lopez and Allyn Smith, operate the second mobile clinic in Marion County. The full team involved with the mobile clinics is as follows:

  • Beth Borders, BS, Medical Services Practice Manager
  • Jeanne Lehman Lopez, BS, RN, Registered Nurse
  • Brandy Fergason, RMA, Medical Assistant
  • Allyn Smith, CMA, Medical Assistant
  • Andrea Henderson, CMA, Medical Assistant
  • Sonny Bennett, Driver
  • Woodie Hutcheson, Driver
  • Kevin Rogers, MBA, Director of Environmental Services & Safety Officer
  • Brent Dugan, Maintenance Technician

Fortunately, the mobile clinic team has found that their extra efforts to treat consumers have not gone unappreciated, especially among family members and loved ones of consumers with severe mental illnesses. According to Beth,

“Sometimes the consumers don’t really realize what we’re doing for them because they’re trying to heal and get better, but the family members do. We had one individual who had just started receiving injections and didn’t have any transportation, so we went to her home and gave her the injection instead. Her mother was home at the time, and she was so appreciative of what we were able to do for her daughter. That was an ‘a-ha’ moment for us. It reinforced that we have to make this work for our consumers, even if they might not realize how important it is for them to get their medication.”

Our medical services team is committed to serving all of our consumers during the COVID-19 crisis—especially those at the highest risk of suffering negative health consequences. We are proud of their innovation with the mobile medical clinics and the hard work they’re doing to continue treating individuals with severe mental illnesses!

For more information about new services Cummins BHS is providing during the COVID-19 crisis, read our articles on telehealth and virtual addiction treatment below!

Explaining Telehealth: How It Works and What to Expect During a Virtual Behavioral Health Session
Observing Alcohol Awareness Month with Cummins’ Erin Flick and Virtual IOT

Women’s Mental Health Awareness: Dr. Corinne Young on How to Provide Effective Behavioral Health Care for Women

For much of history, the mental health struggles and needs of women have been misunderstood. In ancient Egypt and Greece, medical professionals believed that behavioral abnormalities in women were caused by the uterus being incorrectly positioned inside the body. During the medieval and Renaissance periods in Europe, many women with mental illnesses were believed to be witches or possessed by evil spirits. And as recently as the early 1900s, women experiencing symptoms of mental illness were diagnosed with a condition called “hysteria,” which comes from the Greek word for “uterus.”

Fortunately, behavioral health professionals now know that women and men experience mental illness for largely the same reasons. The vast majority of behavioral health issues have nothing to do with a person’s biological sex, and effective treatment for a particular issue looks the same regardless of a person’s gender. With few exceptions, women and men suffer from mental illness for the same reasons resulting from genetics and environmental factors.

However, a person’s gender can affect the kinds of behavioral health problems they are likely to suffer. Due to the different roles women and men have in our society, they are often exposed to different sources of stress and trauma, which can lead to different behavioral health consequences. Effective behavioral health care should take these factors into consideration, anticipating gender-related hardships that a person may be struggling with and working to address these issues when they are present.

In honor of Women’s Health Month observed in May of each year, Cummins Behavioral Health hopes to bring awareness to the unique mental health challenges that women sometimes face. We spoke with Dr. Corinne Young, a staff psychologist who has a strong interest in women’s health, to learn what issues women may struggle with and how care providers can most effectively meet women’s behavioral health needs.

Depression, Trauma, Body Image and Childcare Stressors

Corinne Young, PsyD, HSPP, CSAYC, Staff Psychologist at Cummins Behavioral Health

Although a person’s mental wellness is not predetermined by their gender, decades of psychological research has found that women are more likely than men to suffer from certain types of behavioral health problems. There is some evidence that women’s sex hormones may place them at higher risk for certain disorders, but traditional gender roles and expectations are also key contributors. “Women have historically been more exposed to disenfranchisement, and as a result, women are a bit more susceptible to some disorders,” Dr. Young explains.

For example, women are about twice as likely as men to suffer from depression or anxiety sometime in their lives. Sometimes these issues are caused or worsened by hormonal activity, such as in cases of premenstrual dysphoria, postpartum depression or perimenopausal depression. However, depression and anxiety can also be rooted in domestic violence and sexual violence, which women are significantly more likely to experience than men.

Rates of eating disorders and body-image issues such as body dysmorphic disorder also tend to be higher among women. These problems can be partially attributed to the high standards of attractiveness that Western society expects women to live up to. “Our media really supports a specific image of women and how women are supposed to look, so it is a big influence on body-related issues for women,” Dr. Young says.

Finally, women who have children are often expected to handle the majority of childcare responsibilities, which can serve as an additional source of stress as well as an obstacle to receiving behavioral health care. As Dr. Young explains,

“Women still provide the majority of childcare, so in addition to working outside the home, they have the added stresses of taking care of the children and the household. Women then have the challenge of managing all these competing needs. They may need to focus on taking care of their family rather than taking care of their own mental health needs, not necessarily realizing that in order for them to be a good mom, a good spouse and a good provider for their family, they also have to take care of themselves physically and mentally.”

How Care Providers Can Better Meet Women’s Behavioral Health Needs

Knowing the behavioral health issues that women may be likely to experience, what can care providers do to ensure these issues are addressed? First and foremost, they can work to raise awareness among their colleagues as well as among the general public. The more people understand women’s mental health challenges, the more likely it will be that women who suffer from these challenges receive help. At Cummins, our Cultural Competency Committee works to keep providers informed about the unique needs and struggles of every consumer population we serve.

Next, care providers should make a point to ask women (in a sensitive and respectful manner) if they are experiencing these common challenges. Consumers may sometimes be hesitant to mention these issues on their own, or they might not even realize they are suffering from them. “We need to ask more questions in our assessments and not be afraid to ask,” Dr. Young says. “For example, asking about trauma. We know that almost everyone has experienced some form of trauma, whether it’s ‘Big T’ Trauma—physical abuse, sexual abuse, neglect—or ‘Little t’ trauma, such as losses that may not be life threatening but can affect our adjustment.”

Effective care also means being accommodating regarding women’s barriers to receiving treatment. Providers should understand that poor engagement or attendence do not necessarily indicate noncompliance with treatment, as Dr. Young explains:

“If someone is having trouble with attendance or returning our calls, it might not mean that they’re failing to engage. There are usually other reasons. Maybe they have family responsibilities, or maybe they’re about to lose their job and are just trying to survive. In substance use treatment, for instance, we may be quick to discharge someone if they’re not attending, but we also know that trauma and substance use go hand in hand—that substance use can be how someone avoids thinking about trauma. We need to be sensitive about that, be willing to meet someone where they are, and be able to troubleshoot how to overcome these barriers with them.”

Although women have a heightened risk of experiencing the mental health challenges mentioned in this post, it’s worth noting that effective treatment for women looks a lot like effective treatment for any individual. It is grounded in a person-centered approach that emphasizes listening, asking questions, and striving to treat the whole person.

Cummins Behavioral Health is committed to continually improving our care for consumers of all populations. To better serve women who have suffered trauma, we hope to soon begin facilitating groups using the evidence-based Trauma Recovery Empowerment Model (TREM). We are excited about this opportunity to improve our care for our consumers!

Looking for more articles about meeting women’s behavioral health needs? We recommend our blog posts on trauma-informed care and domestic violence shelters below!

Trauma-Informed Care: What It Means and How It Can Be Implemented in Behavioral Health
Giving Domestic Violence Survivors a Chance at Independence: Cummins BHS, Sheltering Wings and RealAmerica Announce Haven Homes

National Child Abuse Prevention Month 2020: Keeping Children Safe in the Age of “Social Distancing”

“The true character of a society is revealed in how it treats its children.” — Nelson Mandela

We have long known the harmful effects that childhood abuse or neglect (also known as “child maltreatment”) can have on a person’s life. Child maltreatment can lead to long-lasting negative consequences for an individual’s physical and psychological health and create behavioral issues that persist into adulthood. However, it is still shockingly common. In 2018 alone, an average of 9.2 out of every 1,000 children—a total of 678,000 children—were the victims of child maltreatment in the U.S., according to the 2018 Child Maltreatment Report from the Children’s Bureau of the U.S. Department of Health & Human Services. In Indiana, the rate was 16.4 out of every 1,000 children, making our state the 9th highest in the country for reported instances of child abuse.

The Federal Child Abuse Prevention and Treatment Act, passed in 1988, defines child abuse and neglect as “any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.” Since abuse is often perpetrated by a member of the immediate family, the burden of detecting and reporting abuse typically falls on the shoulders of adults outside the family, such as teachers, counselors, relatives, neighbors, medical professionals, religious leaders and members of law enforcement.

However, the ongoing COVID-19 crisis has made it much more difficult for victims of child abuse to receive help. School closures and social distancing guidelines have given children fewer opportunities to interact with individuals who could provide assistance, which means that we must all be more vigilant about detecting abuse. This sentiment is shared by Kevin Carr of Sheltering Wings, a domestic violence shelter based in Danville, IN:

“When families are isolated, the reporting structures for abuse are interrupted. Victims are in closer proximity to their abusers and at the same time are isolated from anyone who could offer help. The primary message we’re trying to convey right now is that neighbors, ministers, therapists—anybody who has the chance of interacting with the family—need to be watching and observing when possible. That takes some skills that we’re not all used to using, or maybe we haven’t developed, but we have to become better at watching and listening closely and being able to interject in ways that are not only helpful, but safe. We’re responsible for each other, and everyone has a part to play.”

Kevin Carr, Development and Communications Officer at Sheltering Wings
Kevin Carr, Development and Communications Officer at Sheltering Wings

In light of the heightened risk of abuse that children are currently facing, and in honor of National Child Abuse Prevention Month, we spoke with Raychel Hamby, one of our care providers who works in coordination with the Indiana Department of Child Services (or DCS). In this post, Raychel explains how we can all spot warning signs of abuse in the children we interact with, including the proper way to respond when abuse is suspected.

Raychel Hamby on the Warning Signs of Child Abuse

Raychel Hamby, LMHC, Montgomery County DCS and Outpatient Team Lead at Cummins Behavioral Health
“I’m the point-person and liaison in our county for all of our services that we provide to those in DCS,” says Raychel Hamby, LMHC, Montgomery County DCS and Outpatient Team Lead at Cummins Behavioral Health.

For many of us, the best thing we can do to help prevent child abuse is know how to detect it. Although some children will speak up about abuse before it becomes severe, many others unfortunately will not. “Through my experience working with DCS for so many years, it really depends on the child’s personality and the family values,” Raychel explains. “In families that teach ‘what happens here stays here,’ those children typically won’t explicitly tell you what’s going on unless it becomes so severe that they finally say something.”

However, there are many telltale signs that professionals who work with children use to spot potential abuse. While these signs do not guarantee that abuse is occurring in the home, they do warrant additional scrutiny and investigation. The presence of multiple signs typically indicates a greater likelihood of abuse.

According to Raychel, here are some of the most common signs of abuse that behavioral health professionals look for when working with children:

  • Suspicious bruises: Bruises that seem unlikely to have resulted from regular play, such as bruises on the face or bruises in the shape of handprints, are some of the most common signs of physical abuse. “The child may say, ‘I fell down the stairs,’ but if you know there are no stairs in the house, then you know that story is not true. And if it’s the middle of summer and the child’s wearing long-sleeve clothes, then the parents may be trying to cover up the bruising,” Raychel adds.
  • Cowering behavior: Physical abuse can also cause a child to develop an instinctive fear response to adults. “When you approach them, they become scared and cower,” Raychel explains. “They’re so traumatized that they feel threatened and respond fearfully to any type of authority figure.”
  • Violent behavior or excessive anger: Alternatively, a child may internalize the violence of physical abuse or perpetuate it as a way of coping. “They could be acting out and hitting other kids, or they could become angry in situations where that level of anger is not appropriate,” Raychel says.
  • Isolating behavior: A child who is being emotionally abused may exhibit signs of developmental regression, which frequently manifests as isolating behavior. “If you know the child is typically outgoing, and all of a sudden they’re isolating and don’t seem like their normal selves, that could be a sign of emotional abuse,” Raychel says.
  • Low weight or frequent requests for food: If a child is underweight or emaciated in appearance, then they might not be receiving enough food at home, which could be a sign of neglect. The likelihood of neglect is even higher if the child frequently comments that they are hungry or asks others for food.
  • Lack of parental supervision: Children who spend a lot of time outside the home without supervision might also be suffering from neglect. This particular sign often indicates that the parents may be using substances. “A major concern for DCS right now is families that are using substances,” Raychel explains. “The children run the street and usually get in delinquent behavior, or they may be using substances themselves.”
  • Many people going in and out of the home: High volumes of traffic in and out of the child’s home can also indicate that their parents are using substances, especially if you don’t recognize the individuals as family members or friends of the family. If the child also exhibits behavioral issues, then neglect as a result of substance use is likely.
  • Rarely spending time outside the home: If a child is rarely seen outside the home, there’s a chance that they are suffering abuse and their parents are attempting to isolate them from others who could help. “Does the child not get to go outside, or if they do, do they have to come back in after a few seconds? Sometimes these are signs of abuse because the parents don’t want others to see the child,” Raychel explains.
  • Cries for help on social media: Finally, children who are suffering from abuse may use social media to alert others to their situation. However, they will typically only hint at their emotional distress rather than disclosing the full nature of the abuse that’s occurring. “In one case I’m working on, the daughter was posting on social media about suicide,” Raychel says. “Her parent’s mental health had gotten so bad that she just wanted out of the situation, and that was a sign of neglect that got DCS involved.”

What to Do If You Suspect Child Abuse

The second component of effective child abuse prevention is knowing how to respond when abuse is suspected. If you believe that a child is suffering from abuse, it is highly inadvisable to confront the suspected abuser directly. While you may feel that it’s your duty to personally put a stop to the situation, it is often wiser to bring in child welfare professionals.

“If your gut is telling you that something is going on in a home—abuse, neglect, substance use, anything of that nature—it’s best to make a DCS Hotline report,” Raychel says. The Indiana Child Abuse and Neglect Hotline is answered 24 hours a day, seven days a week (including all holidays), and the identity of callers is never disclosed outside the agency. Once a report is made, DCS will determine the likelihood that abuse is occurring, send out an assessor if appropriate, and begin the necessary procedures to address the situation.

In addition to securing a safe living environment for the child, DCS may refer them or their parents for services with a behavioral health provider like Cummins BHS. As Raychel explains, the type of support provided can vary widely based on the circumstances:

“We do an intake assessment, make the appropriate recommendations, and then follow up with the family. In general, our heaviest involvement is due to substance use. In extreme cases, the child may be removed from their parents, and the parents would complete substance use treatment. We also have cases where a child isn’t attending school due to their parents’ substance use, so we would help the parents develop structure and address whatever is keeping the child from getting to school. We also work with kids who’ve been through trauma—sexual abuse, emotional abuse and physical abuse—that are in foster care. DCS will usually get us involved to help the foster placement provide support and nurturing to the child they have in their home, because the child will probably have behavioral issues from the trauma.”

The safety and well-being of children is always the top priority when abuse has occurred, but it should be noted that protective services never wish to break up families. Whenever possible, the intention is to rehabilitate abusers and mend fractures in family harmony. As Raychel Hamby says, “Our goal when we get involved is always to assist the family in reunifying. Our goal is never to keep the children away from their family, but to help the family establish healthy boundaries, structures and routines.”

During these challenging times, we are all responsible for the well-being of our most vulnerable community members. If you suspect that a child you know is suffering from abuse, please call the Indiana Child Abuse and Neglect Hotline at 1-800-800-5556 to make a report. Your call may be the critical first step in protecting a child!

Looking for more information about domestic violence and children’s behavioral health? Here are a few more articles we recommend!

Giving Domestic Violence Survivors a Chance at Independence: Cummins BHS, Sheltering Wings and RealAmerica Announce Haven Homes
How Avon Community School Corporation and Cummins BHS Are Supporting Students’ Mental Health

Addiction Treatment for Teens: Introducing Adolescent IOT with Madelin Biddle and Katherine Richards

Despite the efforts of dedicated health care professionals and organizations, substance use continues to be a major behavioral health issue for millions of people across the U.S. According to the National Survey on Drug Use and Health, approximately 20.3 million Americans suffered from a substance use disorder (or SUD) in 2018. In Indiana, the estimated number of afflicted Hoosiers totaled 389,000.

Although not everyone who needs treatment for SUD ultimately receives it, there are today a wide variety of providers and services that can help adults who have substance use problems. However, one population that is sometimes overlooked is teenagers and adolescents. Although 916,000 American adolescents aged 12–17 suffered from a SUD in 2018 (18,000 in Indiana), only 159,000 received any treatment for substance use. In addition, statistics show that the percentage of adolescents with a SUD who receive treatment is consistently lower than among individuals above age 26.

Cummins Behavioral Health has long provided substance use services for individuals who need them, which includes our popular Intensive Outpatient Treatment (IOT) program, but they’ve sometimes been difficult to cater toward adolescent populations. However, we’ve recently launched a virtual IOT program specifically for youth and adolescents to meet the needs of this age group.

To learn more about the specifics of this new program, we spoke with two of its facilitators: Madelin Biddle, one of our school-based therapists, and Katherine Richards, a graduating intern in substance use counseling. They explained the origins of the adolescent IOT program, how it has been received by consumers, and what plans are in place for its future.

Addressing a Difficult-to-Meet Need for Teenage Youth

Madelin Biddle, MSW, LSW, and Katherine Richards, MSW
Madelin Biddle, MSW, LSW, school-based therapist (left) and Katherine Richards, MSW, graduating intern in substance use counseling (right)

Although Cummins’ adolescent IOT program is brand new—it started in Putnam county on April 27th—the need for this type of program is not. “I’ve spoken about it extensively with [Director of Operations for Montgomery and Putnam counties] Rebecca Roy, and she’s been talking about doing this since I first started as an intern a little less than a year ago,” Katherine says.

Traditionally, adolescent consumers who need Intensive Outpatient Treatment for substance use have been integrated into our adult IOT groups. While this policy has allowed younger consumers to receive the treatment they need, they’ve often been unable to undergo treatment with other individuals of similar age. “We had a lot of people who were 17 or 18 in adult IOT, and it very much felt like they could’ve benefited better from a group consisting more of their peers. It was very evident that they would benefit from adolescent IOT, but we just didn’t have one,” Katherine says.

Ironically, the COVID-19 pandemic played a role in finally making adolescent IOT a reality. As most schools remained closed and telehealth services quickly became normalized, some of the obstacles that had previously prevented the program’s implementation were cleared away. “As a school-based therapist, I think the barrier was getting around school schedules. It’s not really our job to pull kids out of school for three hours at a time,” Madelin explains.

“There were also barriers like transportation needs for a lot of adolescents,” Katherine adds. “Being able to do IOT through telehealth has opened doors that were previously closed.”

The Future of Adolescent IOT at Cummins BHS

Although the virtual adolescent IOT program has only been running for a few weeks, early feedback from consumers has been encouraging. “Some of our feedback has been that consumers feel they’re not the only ones who made mistakes and that they feel they can find trust in the group,” Madelin explains.

For some teens, nine hours of group sessions every week seems like a big commitment at first, but Madelin and Katherine have found that many participants end up expressing gratitude for the opportunity to connect with their peers. “When I was first introducing the idea of Group to individuals, I found that the time component was really intimidating for them,” Madelin says. “But I think they’ve been really surprised by how well Group is going. And especially during COVID-19, I think it’s been really beneficial to have that time to meet as a group and that space to talk about substance use with peers where there isn’t such a stigma surrounding it.”

While the program is completely virtual for the time being, there’s a possibility that it will be expanded to include in-person sessions in the future. As with many of Cummins’ services, this depends on how the COVID-19 pandemic changes in the coming months. “We’re waiting to see what happens,” Katherine explains. “If it’s more convenient to continue it online even if restrictions are loosened, then we may do that. But I was hired into my role to do this kind of work, so I believe the intention is to continue the program whether it’s in-person or online.”

In case the program does begin offering in-person sessions, preparations are already being made to remove some of the associated barriers. For example, Area 30 Career Center in Greencastle has indicated that it could assist with providing transportation to and from sessions for students who need it. “I think the intention is to eventually work with Area 30 to reduce that barrier,” Katherine says.

Cummins’ virtual adolescent IOT program is primarily operating in Putnam County at this time, although it is open to individuals living in all counties that Cummins serves. If you or your teenage friend, child or relative is struggling with substance use, we encourage you to call us at (888) 714–1927 and inquire about substance use treatment. Our adolescent IOT program could be a good fit for you or your loved one!

Looking for more information about substance use disorder and Cummins’ SUD services? Here are some more posts we recommend!

Managing Dual Diagnosis: Cummins’ Tracy Waible on How to Identify and Treat Substance Use with Co-Occurring Disorders
Observing Alcohol Awareness Month with Cummins’ Erin Flick and Virtual IOT

Teletherapy for Kids: How to Work with Young Children during Virtual Behavioral Health Sessions

Working with children in a behavioral health setting can be challenging. Care providers may have difficulty keeping young children focused, communicative and engaged in the session even when they are in the same room together. Telehealth sessions with children make this task even harder, reducing the provider’s control over the situation as well as the immediacy of their presence.

We’ve previously shared some tips and best practices for engaging behavioral health consumers via telecommunication, and many of these suggestions can also apply to children. To recap, consumers should be coached through any aversions they may have to virtual care, encouraged to participate with motivational interviewing and rapport-building, and engaged with visuals and activities whenever possible. However, high-quality engagement throughout the session is especially critical with children, as they could easily lose interest when the provider is just a face on a screen or a voice on the phone.

Fortunately, it’s possible to conduct successful virtual sessions even with young children, and a growing body of research shows that telehealth therapies and behavioral interventions for children can be just as effective as in-person treatment. Care providers need only alter their engagement strategy slightly to keep young children interested and interacting in the session.

Dr. Ashleigh Woods, one of our psychologists here at Cummins Behavioral Health, recently held a training seminar to educate our staff on the best ways to work with children over phone or video chat. Her advice can be broken down into two categories: interventions for overcoming technical issues and limitations, and strategies for keeping children engaged during virtual sessions.

Making the Best of Technical Limitations

Ashleigh Woods, Psy.D., HSPP, Staff Psychologist at Cummins Behavioral Health
Ashleigh Woods, Psy.D., HSPP, Staff Psychologist at Cummins Behavioral Health

Depending on the age and disposition of the child, behavioral health sessions with children can be much more “lively” than those with teens or adults. Young children often like to move around, explore their environment and play with objects in the room, especially if elements of play therapy are being utilized in the session. Although these behaviors aren’t usually problematic during in-person sessions, they can cause some disruption when the provider can only see the child through the camera on their device.

Providers can take the following steps to compensate for these technical limitations:

1. Find the best camera position

If you are communicating via video chat (which is recommended over voice-only calls), you should work with the child at the start of the session to determine the best location for your camera. Ideally, you should be able to see as much of the area where the child may be interacting or playing as possible.

“I’ve found in my own work with kids that having the device on the floor tends to work out well for me, because that way I can see more of the space and what’s happening in it,” Dr. Woods says. However, you should also be prepared for this position to change as the child moves to different parts of the room or moves the device, which leads to our next point.

2. Anticipate and be patient about technical difficulties

Providers can save themselves some angst by accepting that no virtual session with a child will go completely smoothly. “As the clinician, we might feel that every minute of the video chat needs to be productive and goal-oriented, but I think that we need to have patience and know that the child is going to wander out of the frame. That’s just a normal part of working in this kind of virtual space with kids,” Dr. Woods says.

Instead of becoming flustered when this happens, respond with patience. If the child leaves the frame, simply let them know that you can’t see them and ask them to come back. Continue speaking to let the child know you’re still present, and calmly encourage them to move your camera or return to view. If you are direct yet reasonable about what must be done, most children will accommodate your needs so that the session can continue.

3. Ask the child to show and explain what they’re doing

Even when you’ve taken the above precautions, there will likely be times during the session when you cannot fully see what the child is doing. Instead of nitpicking the placement of the camera, it is sometimes easier to have the child bring items to you or verbally explain what they are doing off-frame.

“Any opportunity you have to ask the child to ‘tell me about,’ ‘show me,’ any of those kinds of things, you may have to take,” Dr. Woods explains. “You might need the child to be a little bit more aware of the position of the camera and that they might have to hold something up to show you, and they also might have to be more verbally engaged in describing what they’re doing or describing the item they’re holding.”

Improving Engagement in Virtual Sessions

In addition to overcoming technological limitations, providers must also do their best to keep children engaged throughout virtual sessions. Because the provider and child are no longer in the same room, it may be more difficult to build rapport and hold the child’s attention. Providers will need to change some of the ways they interact with children over video or phone in order to keep them interested and participating during the session.

Providers can use the following strategies to improve telehealth engagement when working with children:

1. For first sessions, try a “scavenger hunt” activity to build rapport

It’s important to establish a sense of trust and rapport in your first session with a consumer (especially with children), but this can be slightly harder to do when meeting virtually. If your first meeting with a child is conducted virtually, consider starting with a “scavenger hunt” activity in which you ask the child to find their favorite toys and tell you something about them.

“This intervention can apply for therapy, and it can also be modified for skills training,” Dr. Woods explains. “It’s a nice rapport-building, ‘getting-to-know-you’ activity. Most kids are going to be pretty excited to show off their space and the things they have at home.”

2. Use more verbal communication and instruction than normal

During in-person sessions with children, a significant amount of interaction may be nonverbal. For example, the provider might engage in an activity with the child or read their body language to assess what they’re thinking and feeling. Since this is often not possible during virtual sessions, you may need to rely on verbal communication more often than you normally would. Ask the child how they’re feeling when you can’t determine their mood, and instruct them to show you how they perform certain activities when you can’t do the activities with them.

“In the virtual space, we don’t have the luxury of being in the room with the child to see how the play is going to unfold, so there has to be a little bit more verbal conversation about it,” Dr. Woods says. “This can really encourage the child to get into the play and show the therapist how to play with the item. And as they show the therapist how they play with the item, the therapist can do all of the things they would normally do in play therapy, such as providing empathic reflections, wondering about thoughts and feelings, and seeing what conceptual themes emerge.”

3. Exaggerate your nonverbal communication and cues

Of course, nonverbal communication still has its place during virtual sessions. Facial expressions can be excellent tools for encouraging children or conveying your emotions to them, and inflection can be utilized to draw their attention to certain words. However, you should exaggerate your nonverbal cues when communicating virtually so they are easier for children to pick up on.

“It’s harder to convey emotions via video, so I encourage anyone to practice with that. Use exaggerated facial expressions like bigger smiles, and exaggerate the affect behind emotion words. I think that’s really helpful for getting kids engaged,” Dr. Woods says.

Although telemental health sessions with young children can be uniquely challenging for care providers, a little preparation can smooth over difficulties and make these sessions just as productive and rewarding as any other. We encourage all behavioral health professionals to use these tips to improve the quality of their virtual care sessions with children!

Looking for more information about mental health issues faced by children and teens? Here are a few more blog posts you might enjoy!

How Avon Community School Corporation and Cummins BHS Are Supporting Students’ Mental Health
How One Indianapolis Police Officer Is Fighting Teenage Substance Abuse

Teletherapy Tips: Best Practices for Engaging Behavioral Health Consumers over Phone and Video

The COVID-19 crisis has led to a paradigm shift in the way behavioral health care is provided. With in-office visits now inadvisable, care providers have begun to adopt telehealth technologies on a scale that’s never before been seen. While this rapid change has allowed mental health professionals to continue serving the needs of their clients, it has also created many questions about the most effective way to provide care from a distance.

Perhaps the biggest challenge of telemental health care is how it alters the dynamic of the consumer-provider relationship. In a virtual session, nonverbal communication is more difficult to utilize and detect, which places a greater emphasis on the words spoken in the session. The environment is also less controlled than in an office setting, which makes it harder for participants to focus and allows more opportunities for distraction. Finally, the balance of power is different in a virtual session, as consumers have more agency to ignore provider recommendations, end the session prematurely or skip it altogether.

These issues can be compounded if care providers are simultaneously struggling to adapt to remote work. Working remotely comes with unique advantages and challenges, and many behavioral health professionals may be unprepared for the realities of working outside the office. In addition to effectively engaging consumers over phone or video chat, providers must also take care to manage their environment and behaviors in order to be successful under these new circumstances.

The good news is that telemental health sessions can be just as effective and achieve the same outcomes and as in-person care when conducted correctly. Kristen Yost, a therapist for Cummins’ Marion County school-based program, has developed her own methods for working around many common telehealth difficulties. We spoke with Kristen to learn what obstacles you should expect during a telehealth session, how to engage consumers under the altered dynamics of virtual care, and what remote work practices will help you excel under the new telehealth paradigm.

Best Practices for Engaging Consumers via Telehealth

Kristen Yost, LMHC, School-based Therapist at Cummins Behavioral Health
Kristen Yost, LMHC, school-based therapist at Cummins Behavioral Health

As mentioned above, bringing the consumer-provider relationship into the virtual realm changes the nature of this relationship. Consumer engagement is a continual concern even in face-to-face treatment, but a lapse in engagement during virtual treatment can be more damaging and more difficult to recover from. Therefore, providers must take special measures to keep consumers engaged with treatment when sessions are being conducted virtually.

There are several points in the virtual treatment process where consumer engagement can dwindle. First, consumers may be reluctant to engage with virtual services at all, which could be due to anxiety about the telehealth process or the belief that virtual services are not necessary. “If they were engaged in services before, it would first be helpful to identify the underlying reason for this change,” Kristen says. “It may be anxiety about transitioning to teletherapy, a dislike for talking on the phone, or concern that others may overhear conversations. If these are the barriers, then identifying and working through them would be therapeutic. Otherwise, it may be helpful to work with the consumer to revise or identify new goals, as changes in the environment and daily living may have resulted in a change in needs.”

Second, some consumers might engage with treatment during their sessions but become difficult to contact between sessions. If a consumer doesn’t join the session or answer their phone at the scheduled appointment time, simple forgetfulness could be to blame. “I will work with my consumers to set a reminder alarm on their cell phones for our session. It’s helpful to have them set a reminder to go off before the actual time of the session so they are ready at the scheduled time,” Kristen suggests. “I also ask my consumers to answer the phone even if they aren’t able to meet at that time; that way we don’t have a lapse in communication.”

Finally, other consumers may be difficult to engage during their session or express a desire to end the session early. Kristen explains what she does to work with these kinds of consumers during virtual sessions:

“For my consumers who tend to process information internally (as opposed to those who process by talking out loud), there can be a discomfort when too much emphasis is placed on dialogue. For these consumers, I love doing timelines and/or visuals to guide discussion and understand past history. The option for consumers to share photographs or special objects offers additional ways to engage. For my consumers who communicate via resistance, I use motivational interviewing and rapport-building techniques while also setting firm boundaries. Humor and sarcasm, if appropriate, can be helpful to change the mood and tone of the session. If there is insistence on ending the session, I provide the option of taking a five-minute break. Regardless of how much time they give to the session, I make note of the small successes, and I strive to end on a positive note. And for my consumers who struggle to focus, I make these sessions as active and engaging as I can over the phone. For those with video access and their own deck of cards, I may supplement dialogue or skill-building with a card game. It can also be helpful to add some type of physical activity, such as every time the consumer engages in an undesired behavior, they will then implement a physical activity of their choice. This serves the purpose of bringing attention to the thoughts, feelings or behaviors we are trying to change while also enhancing focus and engagement.”

Best Practices for Adapting to Remote Work

Of course, keeping consumers engaged with treatment is harder if you as the provider are also struggling to stay engaged. Remote work is a new arrangement for many behavioral health professionals, and some might be surprised to find that working from home requires a different type of discipline than working in an office environment. Fortunately, providers can take a few simple precautions to improve their focus and productivity when treating consumers virtually.

It can be tempting when working from home to relax your regular morning routine. Waking up late and working in pajamas sounds nice, but departures from your normal work preparations can instead prime you to be unproductive. “Every day feels like the weekend if I don’t create my own structured work routine at home. I’m trying to make it feel as much like a typical workday as I can so that I keep that mindset,” Kristen says. “This helps me maintain consistency with my own behaviors, which also creates a feeling of familiarity for my consumers.

If possible, it’s also best to work in a different area of the home than where you spend your leisure time. Just as maintaining your normal work routine can help you stay in a working mindset, having separate environments for work and leisure can improve your focus and productivity during working hours. “Setting up an area of my home that I use specifically for work helps me create a conscious separation between work and home. This helps with productivity during the workday and also makes it easier to transition out of ‘work mode’ when my workday is done,” Kristen says.

One more thing to consider is the privacy of your workspace. Anyone else who lives in your home should know when you are working and when it is and isn’t acceptable to disturb you. Setting and adhering to these boundaries is important for the confidentiality of your sessions as well as your productivity, as Kristen explains:

“My family understands the nature of my work, and they are respectful of my need for a confidential space. I make my consumers aware that although I am working from home, their privacy and confidentiality is important to me. I let them know about the measures I have taken in order to provide a secure and safe place to open up, and I ask my consumers to follow suit by finding a space in their homes away from distractions and other people. My hope is for our teletherapy sessions to have the same safe and comfortable atmosphere as when we meet in the office.”

Although teletherapy requires some adjustment on the part of care providers, it is an extremely valuable asset when seeing consumers in person isn’t possible. We encourage behavioral health providers to utilize these tips in their day-to-day work to overcome some of the most common obstacles of telemental health care!

Looking for more tips to help improve your professional skills and behaviors? Take a look at our posts on multitasking and the Imposter Syndrome below!

Stress Can Be Good For You (as in this picture of a woman doing her homework)
Why Multitasking Doesn't Work at Work
Perfectionism and 'Hurry Worry'
Embracing Your Inner Expert: Perfectionism and the Impostor Syndrome in Mental Health