Q&A: Interview with Dr. Brad Sachs

1) Your new book contains letters that you wrote to an adolescent patient named Amanda, who came to you for treatment after a failed suicide attempt and several previous unproductive attempts at therapy. Knowing her history, what did you decide to do differently in an attempt to heal her pain, especially when she made it clear to you that she didn’t want to work with you?

The reality of psychological treatment for most adolescents is that they are coming “under protest”, because they are made to, not because they necessarily want to. However, the reasons behind why they don’t want to, why they often resist conscientiously participating in treatment, generally have to do with their and their parents’ preconceived notions regarding the premises of therapy—for example, the assumption that there is something wrong with them, or that they are going to have to give up some hard-won part of their identity, or that they will be the only ones expected to make changes while everyone else in their family is entitled to stay the same.

With this in mind, Amanda, like many teenagers, initially refused to participate in the sessions. She attended, but would sit in her chair stonily and silently, daring me to try to cajole her into conversation, and making it clear I would not succeed in doing so.

When the therapist is able to help adolescents and their families see that treatment is a collaborative venture, however, when they begin to realize that the problems that brought them into the consultation room are actually misguided attempts to solve problems, and when they are offered innovative and healthier problem-solving strategies, they usually join in conscientiously.

So while Amanda had been in treatment with several different clinicians prior to meeting with me, in all of those cases it was my sense that treatment simply confirmed her and parents’ belief that her difficulties were the inevitable result of deep-seated, internal, neurochemically-based imbalances, a belief that diminished her and her family’s optimism, motivation, and responsibility for making changes.

My job, as I saw it, was to dislodge their previous assumptions about effective psychotherapy, expand their understanding of the present situation, and to do what I could to present a more hopeful and creative approach to getting her unstuck.

2) What made you think of writing letters to her?

The traditional model of psychotherapy that is offered to adults—entering the office, sitting down, conversing one-on-one for 50 minutes, and then leaving—has little relevance, appeal or value when it comes to working with adolescent patients. Some will tolerate it better than others, but few will change in significant and enduring ways as a result.

So I am always looking for innovative ways to engage with adolescents, to jointly discover the often-hidden paths that lead to some connection, some trust, some healing.

In Amanda’s case, I noted that she had excelled in her English classes, and clearly was comfortable with reading and writing, so I thought that composing  letters to her in between sessions would be one way to help her to see that there are many ways for individuals to communicate with each other.

This was not the first (or the last) time that I chose to write to a patient in between sessions, by the way. Particularly with children and adolescents, between-sessions contact is a way to reassure them (and their parents) that they remain important even when they are not in the office, that what they think and feel matters to me beyond the time that they are in my presence.

3) What did you write to her about?

Initially, my letters were simply intended to convey to her that this time, treatment was going to be different. I had to make it clear that I wasn’t going to just put her though another ordeal of pointless individual psychotherapy when it was quite evident that she and her parents were all sagging under the weight of a tremendous amount of family stress. I had to begin to lay the groundwork for my belief that, in my eyes, she was more oppressed than depressed. And I had to persistently convey to her my faith in her strengths, her resilience, and her resourcefulness, particularly during a period of time when she didn’t have much faith in herself.

As she began to regularly write back and buy into our correspondence, my letters were usually a response to hers, and addressed the matters that she brought to my attention in her missives, and that her parents brought up in our sessions.

Later on, as she began to participate more actively and verbally in our face-to-face family sessions, we would use the letters to explore in more detail some of the themes, issues, and encounters that arose during our appointments

4) How did you integrate the individual letter-writing relationship with her with the family-treatment approach that you felt was necessary, and how did this play out over time?

There is no question in my mind that family-based treatment is the treatment of choice with children and adolescents, the best, and sometimes the only, way to promote lasting growth and healing. Whenever a child is presenting problems, the entire family must become part of the solution. That is because the symptoms that teenagers present are usually designed to call attention to the family’s inability to evolve, to move from one developmental stage to the next. I don’t believe that fault-finding or finger-pointing has any useful role in family treatment, but I do believe that psychological distress does not occur in a vacuum, and is most effectively alleviated when the generations join together to help each other move forward

With this in mind, my letters to Amanda were designed to be a starting point in treatment, but not an endpoint, a way to build enough trust and therapeutic momentum that Amanda could eventually see the value of actively participating in our family therapy sessions. Once that momentum had been established, I gradually chose to ratchet down the extent of our correspondence, although we continued to write to each other infrequently until the end of treatment, and once she left home for college.

5) Why aren’t Amanda’s letters included in the book?

I originally envisioned and wrote WHEN NO ONE UNDERSTANDS as a dialogue, one that included both my letters to her and her letters to me. However, several of the individuals who read over that draft of the book found that reading Amanda’s letters had a distancing effect—it made it difficult for them to apply what I had to say to their lives, because they were so focused on Amanda’s life and its attendant drama.

So I rewrote it as a monologue, and discovered that readers of that draft were much better able to take in and respond to what I wrote. Perhaps this was because the details of Amanda’s life were so overwhelmingly painful that it made the experiences of most readers pale by comparison, rendering them unable to resonate to the general perspectives and insights that my letters offered, and that are applicable to any individual, either currently or formerly an adolescent.

Amanda, who I have stayed in touch with, originally gave me permission to use her letters in the book, with the understanding that I would change many of the identifying details disclosed in her letters and in mine (changes which I of course made). However, she did admit to some understandable relief when I eventually told her that the book would not include her letters after all. While this story has a happy ending, our work together occurred during an excruciating time in her life, one that she would understandably not want to have to re-visit very often.

6) What was it about your letters that helped Amanda to open up to you?

Obviously, I thought very carefully about how to engage with Amanda through letter-writing, and approached it with a good deal of care and delicacy because not only the trajectory and outcome of her treatment, but her very life, were at stake. I knew that I had to make it clear to her that our work together was not going to simply replicate the somewhat unsuccessfully therapies she had already undergone. I knew that I had to convey to her that I wasn’t interested in changing her or helping her or improving her, because that automatically arouses a teenager’s resistance. And I knew that it would be unwise to be overly optimistic or cheery, particularly with a young lady who was so filled with despondency and despair.

Instead, I took the approach of being interested in her, of wanting to become acquainted with her, to know and understand her as well as I could. After all, that is the deepest wish that all of us harbor—to be truly known, understood and accepted by others. And I worked hard to attract her curiosity about herself by presenting to her some new, positive and intriguing ways of understanding her sometimes mystifying and troubling behavior.

Once I was able to reassure Amanda that I wasn’t invested in making her “better”, but that our letter-writing and conversations might ultimately enable her to create a new framework within which to make sense of and appreciate herself, she gradually was able to take the risk of reaching out to the hand that I was extending, so that I could help pull her free.

7) In your letters you resist the idea of diagnosing Amanda with depression or any other psychiatric disorder, even when she presses you for a diagnosis. Why wouldn’t you offer her a clinical diagnosis?

I wanted to be absolutely clear from the very start of treatment, both with Amanda and with her parents, that we have too greatly narrowed the definition of what constitutes healthy psychological development, and that these days even the slightest departures from this artificial norm are characterized as diseases, disorders, and disturbances. Once we begin the process of labeling children and adolescents, we automatically begin the process of dehumanizing them, of making them into patients rather than people.

This tendency of ours has tremendously worrisome implications, because by overly restricting the definition of health, we reduce an individual’s complicated behaviors to mere symptoms and then lose the capacity to see that much of what is symptomatic is actually a valiant attempt, albeit maladaptive or dysfunctional, to express important truths and convey meaningful insights.

I believe that Amanda, in initially insisting that I provide her with a “diagnosis”, was actually testing me in an effort to determine if I was going to fall into the same immobilizing trap that her previous clinicians had, or if I was going to persist in my effort to envision her as a complex, anguished but ultimately healthy young adult who required a more optimistic and useful interpretation of her self-destructive tendencies.

8) The National Institute of Mental health estimates that 1 in 8 adolescents suffer from depression. Suicide is the third leading cause of death among adolescents (also according to the NIMH), and the rate of suicide among 15-24 year olds has tripled since 1960. Why are rates of teen depression and suicide so high, and what can we do to reverse these troubling trends?

There are many reasons why the suicide rate amongst adolescents remains as high as it is, and it would be difficult to do justice to this to this question in a few sentences.

I do want to focus on one issue, however, which is that I believe that every adolescent is striving to create a life of purpose, and that our culture seems to do less and less in an effort to help young adults to do so. We focus so much on achievement, accomplishment, acquisitiveness and competition that the more enduring human values, such as kindness, generosity, compassion, and ethics are neglected or ignored altogether.  We insist that “you are what you have” when in reality it’s who we are and how we love that ultimately defines the kind of person we become and how meaningful our lives are. 

As I mention in one of my letters to Amanda, we bombard young adults with overstimulating sexual imagery while terrifying them about the hazards of sex, and then expect them to miraculously find a sane and healthy way to channel their sexual energies and explore physical intimacy. And all of this takes place in a society in which the economic gaps between the have’s and the have-not’s grows wider each year, in which our most precious cultural commodity—the family—is constantly undermined and undercut.

With this in mind, the dangerously high teen depression and suicide rate is hardly a coincidence but is, to my way of thinking, the unavoidable outcome of the unhealthy and under-nourishing psychosocial environment that we have created for our children, and for the parents who raise them.

9) Related to this issue, you offer to Amanda your belief that much of what we call adolescent “depression” can be better understood as adolescent “mourning”—what do you mean by that?

It is impossible to become a healthy adult without saying goodbye to one’s childhood, and I believe that one of the reasons that adolescents so regularly encounter feelings of sorrow and despair is because adolescence is by definition a time of grief, a phase during which they must mourn for the end of their childhood in preparation for taking on the mantle of adulthood.

When we minimize or ignore the considerable mourning that every adolescent must endure, we become much less able to empathize with and understand the struggle that they are in the midst of, and less effective at conducting and supporting them through their grief so that they can move on to the next stage in their development.

Most of the adolescents who are referred to me for depression, and for a wide range of other maladies common to teenagers, are, to my way of thinking, not emotionally disturbed or mentally ill, but grief-stricken, trying desperately to find a way to make sense of the overpowering sadness associated with mourning the death of their childhood. Unless we are prepared to speak and teach the language of loss to our teens, they will be less capable of growing from, and through, this loss.

10) What do parents need to know about talking to teenagers who seem depressed and/or withdrawn?

You cannot force an adolescent to talk with you, but you can act in ways that raise the odds that some form of meaningful contact and connection will naturally and spontaneously take place.

For example, it was clear from the start that Amanda was not going to speak with me, and that there was no way that I could make her speak with me, but it was just as clear that she was desperate to communicate with me, and that it was simply a matter of finding the right communicative vehicle for doing so, which, in this case, was through letter-writing.

Parents need to broaden the definition of what “communication” consists of, and try to find the best possible communicative apparatus. Sometimes it will take the form of a consensual verbal exchange, and it’s great when that happens, but parent-teen communication need not be limited to that kind of interaction—parents can also write letters, stuff notes in backpacks, send e-mails, get on Instant Messenger, go on errands or take walks together, and somehow find new ways to exchange their thoughts, feelings, and love.

It is also important to remember that all of the adolescents whom I’ve treated, without exception, truly want to be able to communicate well with their parents—to listen and be heard, to understand and be understood—but have come to gradually believe, for whatever reasons, that they’re not going to be listened to fully and thoughtfully, and that they’re not going to be spoken to in ways that enhance their self-esteem and self-confidence.

With this in mind, parents have to become very observant of their own behavior, and take note of how generously and attentively they are willing to listen to what is on their teenager’s mind, even if they don’t agree with it, and how respectfully and candidly they talk to their teenagers, even if they are angry and upset with them.

11) We read a lot of stories in the news lately about the rising use of antidepressant medications among teenagers. Some researchers and clinicians think that these medicines are over-prescribed and unsafe for teens. What is your view on treating teens’ emotional problems with medication?

There is no question in my mind that psychotropic medications have alleviated unnecessary emotional suffering for many children, adolescents and adults, and we should never automatically rule out any intervention that might be of assistance to a depressed adolescent.

However, there is also no question in my mind that we have become over-reliant on conceptualizing and treating adolescent anguish with medication. We are frequently prescribing medications for children and adolescents that have only been tested on adults, with little understanding of, and no long-term data on, the impact of these medications on the developing brain. Psychotropic drugs are quite often prescribed by physicians who have had no extensive mental health training, and/or without a complete psychological evaluation having ever been undertaken or completed, sometimes after as little as a single 30-minute consultation.

We also have to remember that every medication has side-effects. Sometimes the side-effects are biologically-based, such as physical discomfort, dependence and addiction, or the unfortunate outcome that can result when a teen is taking medication but also using alcohol or recreational drugs.

Sometimes the side-effects are psychologically-based, such as when adolescents are told that they have a “disease” or “disorder”, and they, and their parents, are then deprived of an opportunity to learn important things about themselves, to build their collective self-assuredness through a  marshalling of  inner resources in an effort to manage pain, handle disappointment or surmount obstacles.

So while I believe that medication can be a useful tool in assisting adolescents when their emotional distress becomes overwhelming and significantly interferes with their lives, I also believe that we may inadvertently create more problems than we solve if it becomes the only tool at our disposal.

To my way of thinking, the most powerful anti-depressant for adolescents is a commitment to helping them to develop healthy relationships, a sense of belonging, and a life of meaning. This commitment became the foundation for the growth and healing that Amanda and her family eventually experienced.

12) In your experience, what are the most effective treatments for depression in teens?

As I noted above, there are many reasons why adolescents experience anguish, which means that there are many ways in which we must help them to not only survive and ease that anguish, but also to grow from it.

We must find ways to help teens discover a sense of purpose beyond their becoming mindless achievers or consumers. We must honor and take seriously the complicated mixture of feelings that accompanies the end of childhood and the beginning of young adulthood, and encourage them to make sense of and give voice to their deepest fears, sorrows, longings and dreams.

While psychological and psychiatric treatment will at times be indicated, those treatments have to be framed in the context of sponsoring the growth of the adolescent’s heart, mind, and soul, rather than simply eliminating their symptoms and improving their behavior. And unless the adolescent’s family is participating in that treatment, changes will either not come about, or the changes that do result will be minor and ephemeral.  

Adolescents are the truest mirror of a society’s values and evolution. When teens are suffering, everyone must be held accountable, and we all become responsible for changing the conditions that enable them to become the effective stewards of the world that they will inherit.