Steven J. Welton, MD, PLLC
4801 Hermitage Road
Suite 103
Richmond, VA 23227
(804) 513-3257

How to make an appointment

Doc Welton

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About Dr. Welton

General Policies & Financial Obligation


Psychiatric Services in a Private Fee-for-Service Setting

Scope of Practice:

Steven J. Welton, MD, PLLC provides psychiatric care to Adult and Child/Adolescent Patients who require assessment and management of a variety of emotional disorders. These include:

  1. Affective Disorders to include Depression and Mood Difficulties
  2. Anxiety Disorders to include Generalized Anxiety, Panic, Phobias, Social Anxiety, Posttraumatic Stress, and Obsessive Compulsive Difficulties
  3. Attention Deficit Hyperactivity Disorders
  4. Developmental Disorders in Children and Adolescents to include Separation Anxiety, Autistic Spectrum, Impulse Control, and Behavioral Problems
  5. Situational and Adjustment Disorders including grief responses and other specific reactions to divorce, separation, and re-marriage
  6. Low grade substance abuse disorders but in context of a primary psychiatric difficulty, i.e someone who may be using substances to self-medicate their difficulties.  However there is not expertise to provide sophisticated substance abuse management where it is the primary presenting concern.

Primary focus is establishing a comprehensive understanding of the psychosocial and neurobiological/genetic contributions to difficulties and providing appropriate medical and pharmaceutical interventions specific to my patient’s needs. Any Psychotherapy or Family Therapy provided would be short term with specific goals and focus essential.

This practice is PART TIME and my level of availability limited, so that acute crisis that require intensive interventions are likely not appropriate for my services. Nonetheless, as a skilled clinician that has 40 years of practice experience, acute turmoil in anyone’s life is sometimes unpredictable, and if I have accepted you as a patient, I will do my best to serve those needs as they arise.

Entrance to 4801 Hermitage Road, Suite 103, RVA 23227

4801 Hermitage Road, Suite 103,  Richmond, VA 23227

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About Dr. Welton

B.S. North Dakota State University, 1970
M.D. University of Minnesota Medical School 1974
General Psychiatry Residency, Menninger School of Psychiatry, 1977
Child/Adolescent Fellowship, Menninger School of Psychiatry, 1978

Dr. Welton is a board certified Child/Adolescent and General Psychiatrist with over 40 years of experience in providing mental health services.  His early career was in New York City were he worked in Social Service and was involved in Community Mental Health and Training in Child/Adolescent and Family Therapy for a large agency that had offices in Manhattan and Brooklyn.  This grounded him in a psychosocial model of intervention and helped him to solidify his understanding of family systems.  This provides him with a unique perspective when assessing patients in understanding the contributions of context and family dynamics across the age spectrum.  His move to Richmond in 1989 lead to new experiences in providing hospital care and residential treatment in a private psychiatric hospital setting during his initial time here.  A slowly growing private practice ultimately became his central focus evolving into his managing role in a multidisciplinary clinic called Village Family Psychiatry.  Here he worked with another psychiatrist, psychologists, clinical social workers, and professional counselors to deliver care to a broad range of ages (2 years to 75 years of age). 

Now he is evolving once again into what he references as semi-retirement (which working 2 days a week really seems).  He brings the same energy, expertise, and devotion to his patients that has been a hallmark of his long years of service to the Richmond community.  It will give him the necessary time in this phase of his life to pursue his passionate interest in gardening, for involvement in his beloved Northside Richmond Community (Ginter Park), and for travel that will be more flexibly possible with a limited work week.  He is excited that his new office is now more imbedded in that local community.  Just as he sees the family system as a vital building block for all development, he sees the community as the entity where we can have the most influence and contribute in the most meaningful way at this moment in our culture.

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General Policies and Financial Obligation

  1. Steven J. Welton, M.D. PLLC is operating as a fee for service practice and you need to be aware he is not a participant in any health insurance panels or organizations.  It is expected that your fees will be paid by credit card, check, or cash at or before the time of service.
  2. The practice has no provision for billing patients or accruing any kind of balances on your account.
  3. Appointments cancelled within less than 48 hours of the appointed time will be charged at the full rate of the appointment scheduled.  Because of his limited schedule there will be no exceptions to this requirement including sickness (patient or family members), work demands, or transportation issues.   Appointments cannot be rescheduled until any fees related to this are paid in full.
  4. Services provided will be charged as follows:
    Initial psychiatric assessment: 45 minutes  $ 400.00
    Routine/uncomplicated medication Follow-up: 15 minutes $ 125.00
    Complicated extended medication Follow-up: 20–25 minutes $ 200.00
    Psychotherapy/Family Therapy: 45 minutes  $ 300.00
    Extended telephone consultation, report preparation, and other requested services charged for each 15 minute Increment of professional time required $ 100.00
    Legal fees for record review, transportation time, court appearance charged hourly $ 600.00
    Record review for prescriptions provided outside of regularly scheduled appointment times $   30.00
  5. Individuals with Medicare will agree to sign an opt out waiver for Dr. Welton acknowledging their understanding that his charges are not reimbursable through Medicare or any secondary coverage they may have.
  6. Patients with health insurance can receive a statement for services rendered that they can submit directly to their insurance carrier themselves for any “out of network” benefits they may have.  They would then be reimbursed directly by the insurance carrier.  Dr. Welton will not be involved in this process and it will be entirely at your discretion should you seek such reimbursement.
  7. At Dr. Welton’s discretion, cumbersome prior authorization procedures for medication prescribed required by your insurance carrier will generate charges for his time.
  8. At the time of your initial registration into his practice you will sign an agreement that you have read and understand these financial policies and will abide by them as long as you are his patient.  You will further attest to an understanding that the scope of his practice is part time in nature and his level of availability will be restricted to the part time hours of his work week.  You will agree to seek help in a crisis situation by going to the Emergency Room of your local hospital or call 911.  Patients who are unable to follow these guidelines and requirements either because they chose not to do so or the nature of their disorder requires more intensive care will agree to seek help elsewhere and be discharged from care at Dr. Welton’s discretion.

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It is my policy that unless you are fully vaccinated (which by definition at this point has an evolving meaning), you cannot come in-person for any psychiatric service that I provide in my office.  There is no mandate to show “proof of vaccination” but I would expect you to be honest in your situation and own whatever your status may be.

The rationale behind this policy is 2-fold:

  1. The current evidence base is that vaccination is highly effective, safe, and to receive it is the recommendation of all knowledgeable healthcare practitioners.  Some variants of the vaccine are over 90% effective which in medicine is an astonishing accomplishment.  Furthermore, as a physician, it is my duty to practice (when at all possible) in accord with the evidence base in my field of specialty, and to respect and adhere to the evidence base in other areas of medicine as well.
  2. Psychiatry is unique in that emotional well-being is signaled not only with words, but with body language, the tone of communication, as well with facial expression.  Mask-wearing makes this difficult and at this point I only feel safe to be maskless around vaccinated people.  I chose at this point to not have to wear a mask in my office.

I will continue to provide virtual interventions, whether by telephone or Zoom.  I will try not to be biased in my intervention with you, but I will likely encourage you to think about your vaccination decision as part of my effort to keep you well and safe.

There remains the option for vaccinated patients who feel more comfortable managing sessions virtually, to also do so.  For many, virtual telephonic sessions have been highly effective and efficient.  While safety can be a factor, I am open to continued contact in this way for any number of reasons.

How to Make an Appointment

If you are a returning patient who has seen Dr. Welton in the past but not in this location or a new patient who has never seen Dr. Welton, please call the office number, (804) 513-3257 and leave a message with your name, telephone number and brief description of your needs.  Someone will return your call, gather more information, determine if you are an appropriate candidate for this part time practice, and if so schedule an appointment time and register you into the system.

Once you have been registered into Dr. Welton’s system, you will get an email through your email address that will provide information as to how to use the patient PORTAL on this web site.

About the Portal:

The patient portal is a mechanism for entering a secure cloud based electronic system called Dr. Chrono.  Your information is securely protected in this HIPAA compliant environment and includes a mechanism for messaging Dr. Welton in a secure manner (rather than using the telephone), as well as scheduling future appointments and paying for fees.  Credit card information provided will be safe in this secure site.  Dr. Welton will also use this system to document his medical interventions, provide e-prescribing to the pharmacy of your choice, as well as ordering any necessary lab testing.  The goal is a paperless system that will be efficient and easily accessible.  If you have concerns about this system you can process this with Dr. Welton or his assistant.  However, if you are uncomfortable with your information being stored in this system, you will need to find other help as he has no other provision for providing care.

Patient Portal

About Dr. Welton

General Policies & Financial Obligation


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Musings from the Frontline

My hope here is to provide some thoughts on current events, trends in mental health, and reasoned thinking about how all of us struggle to survive and cope with the complexities of living in this day and age. I hope to provide a perspective, infused with living a long life here, practicing psychiatry for 40 years, and grounded in some knowledge base/science. I hope it provides reason to visit my website even if you may not be my patient. Sharing my perspective is a daunting enterprise, but I think it will be good for me to hone my writing skills and hopefully for you to find some “pearl of wisdom” in these musings. ©2021SteveWelton


What About Cannibas?

I am increasingly perplexed and challenged by the aftermath of legalizing marijuana in the Commonwealth of Virginia.  Patients are now actively inquiring about Cannabis concerning what are its uses and is it an option in regard to managing emotional struggles?

Let me start with a basic and intrinsic challenge in this process.  There are no good random controlled placebo driven studies when it comes to cannabis.  As such there is no good evidence base from which to provide guidance to our patients.  Anecdotally we know that there are many individuals who purport that cannabis eases anxiety, facilitates sleep, keeps people focused, etc.  But the evidence base is not yet available and regrettably it appears unlikely that this will eventuate.  There is no “money to be had” in relationship to “proving” the efficacy of cannabis, as the sources of supply are so diffuse and “easy”.  Anyone in the state of Virginia can grow up to 4 plants on their property and there is no longer a vested interest from pharmaceutical companies or even a drug cartel in “proving” its efficacy.

As such, we are in a position of trying to provide guidance and understanding when we do not have an evidence base.  So, since the evidence base is lacking, do we simply ignore this agent as a viable intervention, or do we find some strategy that is thoughtful and informed to the degree that is possible.  I would propose that this is what we must do as it has become an ubiquitous part of our culture and our way of coping.

I have always suggested to my patients that alcohol is disinhibiting and often a very bad “drug” for people who have problems with impulse control and already struggle to “rein in” their emotions, esp. anger.  It is likewise problematic that cannabis for some late adolescent (esp. males) can be a sink hole that perpetuates mindless preoccupation with videogames and similar genre.  But I am also aware of individuals who suggest that a bowl of cannabis before bed allows them to sleep through the night without significant hangover, that it eases anxiety according to some, and that for others it contributes to focus and concentration.  Clearly there is a differential response from one individual to the next. There are strains of cannabis that are different inducing unique responses in different individuals.  In this measure there are issues intrinsic to the individual (perhaps neurobiologically determined) as well as different responses to different strains of the drug.  Just as with all medicines for hypertension, diabetes, and elevated cholesterol, there are those that impact people positively and those that are problematic and create adverse side effects.

I would wonder is it better to take an Ambien or Lunesta tablet to facilitate sleep than a bowl of cannabis.  I know that in some individuals Ambien leads to a kind of “blackout” during which they eat, have sex, and even drive and have no recollection of this happening. Is this risk more worthy of tolerating than not having the evidence base for cannabis?  Is it better to take a drug like Adderall for focus, if someone has a reasonably positive experience with cannabis for its similar impact. Certainly, there is no appetite suppression, sleep disruption, or even aggravation of mood with cannabis that there can be with psychostimulants. Anxiety tends to be a very complicated emotion and while many report aggravation of anxiety states with cannabis, there is clearly a group of individuals who report relief from anxious states with cannabis.

I am concerned about the pulmonary impact of “smoking” cannabis, but there are now edibles that get ingested through the gastrointestinal tract and do not impact lung function.  We know that in adolescents, cannabis can impact brain development and contribute to cognitive difficulties.  This could be a concern with adults as well.  This is the data we don’t have and what makes offering advice and direction difficult.

Nonetheless, I contend that as physicians and esp. psychiatrists who specialize in human emotion, we must confront the complexity of cannabis.  It is not only an agent that can be misused and abused, but an agent that can have beneficial and salutary effects for some.  How to come to a realistic and measured position when it comes to cannabis is a growing dilemma. It clearly deserves attention and thoughtful dialogue amongst all who struggle to help individuals find comfort, solace, and healing for their emotional ills. [JAN 2022]


Emerging From the Shadows

Thinking about what it now means to be vaccinated and ready to emerge from the shadows.  We have learned and heard a lot about safe behaviors, masking, social distancing, and all of the things that have kept us safe this last year. Now we must learn something about emergence, a kind of rebirth as it might be envisioned. Just as we constricted our lives (although it was in one fell swoop) we have to slowly emerge, re-engage, and make contact with each other in a more intimate way once again. Human nature requires such contact for us to live harmoniously amongst each other. So for me the process has begun.

Last Wednesday night was the eve of my 2 week post-2nd vaccine. Supposedly 14 days to achieve maximal effect. (Moderna is 95% effective!!! ) There  is almost nothing that happens in medicine where those are your odds. People have every right to question what they put in their bodies. But I assure you in the scheme of things, ALL OF US have put so much junk in our bodies that is so much knowingly worse than this.  So, I’m a believer. (I do add the protest that until recently science was not considered a “belief system”). So in the backyard of a neighbor this week celebrating a birthday and able to enter the backyard and HUG the birthday man and then proceeded to hug 2 others. I confess, I’m a hugger and sometimes struggled pre-Covid with making sure I was not stepping on physical boundaries, but with my closest of friends….come-on! I then enjoyed a whole evening sitting closer to people and not being afraid.

I can be called out for not adhering to all of the social distancing parameters which we are encouraged to do even post-vaccine, but I also think we need to give some voice to moving back towards some norm of warmth in our connections and friendships. I promise to be selective and prudent, but just as schools need to reopen, we need to be able to re-engage with our family, our friends, and our trusted associates. I am fortunate to belong to a group of society that has embraced all the necessary rules. I had one event in my living room this winter on Christmas allowing my friend Scott into the inner chambers as he was alone on that special day, but that was my one incursion into risk. This past Friday I had good friends both vaccinated come and sit by the fire in my living room. I felt so liberated. I won’t have anyone in, but I think it’s ok to evaluate your “prudent” risk and go for it.

I have been preaching a bit about the responsibility of having been chosen for vaccination. It is at this moment, a privilege and an honor to be this group. Who would think that old age had such advantages. I do confess mine came via being a medical professional, but I do fit this “old” group as well. Now we wise old folk will need to lead us out of this social isolation and back into the world of engagement and connection. It is our charge, so to speak, while we still listen to Dr. Fauci and follow precautions that are reasonable in public and when you don’t know your players. But I contend we need to take our risks and chances with our family and friends and begin to repair our tarnished souls that have endured separation and loneliness to save our way of life. Now we need to save our way of life by taking life back. Remember, IT TAKES A VILLAGE. [FEB 2021]


The Challenge of Maintaining Political Neutrality in a Mental Health Practice

It would seem now is an especially good moment in our history to address the subject of political neutrality.  Ever since I was initially trained in psychoanalytic psychotherapy, the concept of the therapist as a neutral screen has been part and parcel of my understanding of what makes for good treatment.  The patient can project onto this neutral therapist any and all kinds of feelings and thoughts without fear of censure or judgement.  To have been trained to give nothing away in regard to your own feelings and thoughts is an amazing experience and took years of challenging supervision to achieve (or at least approach achieving).  When I really functioned as a therapist, this made a great deal of sense to me and I didn’t ever question the wisdom of maintaining this “frame” as critical to the healing process.

Now, however, I have become a “doctor”, in as much as I diagnose, search for understanding and often prescribe treatment.   Mostly we think of this as prescribing medication, but we also prescribe exercise, better eating patterns, safe sex and sleep hygiene to name a few.  We “know” what makes people health emotionally and we impart this wisdom as a basic axiom of our service and care for a patient.  If you’ve gone this far with “intruding” so directly in an individual’s life, isn’t it a logical leap to then also prescribe “appropriate relationship interaction” and “appropriate ways of contributing to society” and “rational belief systems”.   As we venture into this terrain, the water gets exceedingly muddy.  There are myriad reasons why an individual patient may have a political viewpoint that seems “mindless”, “simplistic”, “irrational”, and “self-centered”.  Some patients crave a simple solution.  They struggle to deal with complex variables that have to be thought through and metabolized and instead prefer an assured vision of what’s right and what’s wrong.  The zone of grey is too frightening and generates enormous anxiety.  It’s not dissimilar from any belief system/religion.  Believing in “a savior” has been part and parcel of many of our experiences growing up in this country. Belonging to a movement or being part of a political vantage point can serve identity and stabilize internal distress and confusion.  This sounds somewhat pompous as I read it, as I think it disrespects the enormous complexity that just surviving in this day and age entails.  There are ardent believers all over the political spectrum and I’ve encountered closed minds on both sides of the spectrum.  Political identity can be an extension of the self and finding comfort in the group is a human propensity.  We are driven to relationship and to attachment if we have had a modicum of nurturing in our years. If not, then sociopathy rules the roost.  Most sociopaths do not seek mental health treatment at least voluntarily.   

So, back to the wisdom of maintaining political neutrality.  Much as I would like to “educate” and “steer people” towards “my reality”, it is not my place as a physician and healer to make this my charge.  My role has to be helping people achieve a sense of safety and comfort in their world, whatever shape that might take.  That isn’t to say we don’t “intervene” to prevent self -harm or harm to other people or even engaging in illegal behaviors.  We don’t turn a blind eye to child abuse or elder abuse or any kind of abuse.  That is altogether another realm of concern and beyond the scope of what I would call political priorities and beliefs.  These are foundational and no more amenable to my “judgement” than a belief in Jesus, Allah, Buddha, or whatever God someone embraces.  They form and serve identity, security, and stability for that individual.  Tampering with this is a dangerous enterprise for a physician and one that requires steadfast thoughtfulness to resist this temptation. EVEN NOW. [Jan. 2021]

?Whatever Happened to Honor

I haven’t really “mused” in a long time and really need to be more diligent about it.  Today inspired by the expected/unexpected passing of Justice Ruth Bader Ginsburg.  She was a truly remarkable civil servant and served our country and our courts so admirably through her long career.  I know I am a partisan, white and privileged, but I am also a United States citizen who grew up in an era when we actually came together and “honored” “our” fallen heroes.  I was just 14 years when Kennedy was assassinated and even though my family was thoroughly Republican, we sat mesmerized for several days as we churned though our national grief and “honored” this young President who had tried to lead with such enthusiasm.  Our affiliations on “pause” we were brought together in a shared unexpected grief to give honor to his service and his sacrifice.  It has a way of binding fear and irrational emotions that truly serves a useful adaptive strategy for surviving as human beings.  There are untold other heroes and ordinary citizens that I have come to honor over these last 56 years since that first event rocked our country back in my adolescence.

So now I work to honor Ruth Bader Ginsberg.  So lucky to be walking the beach in North Carolina and watching the ferocity of the ocean rumbling into shore.  Thinking of this small “titan” who inspired us all with such courage and moral commitment. Trying in my own quasi-spiritual way to thank her for coming into our world and doing her best to make her mark in a meaningful and virtuous manner. Then into this serene beautiful picture of normative grief and intimate honoring pops an intense fear of her death being used for political and cultural gain. We were so intent on preserving “our” seat that we hoped against all hope that she would survive November. We couldn’t even let her die with dignity and when “her time” called her.   Again, I am not so much trying to justify my proclivities (although the fear is born of that) but trying to keep holding on to the notion that as a nation we need to honor her service. We should not at this point already be encumbered by “what’s next”, but to truly mourn and grieve her passing.  Is it not honorable to do this? What has happened to our nation that we cannot take the time to do this.  What about honoring her dying wishes that the next president (be it Trump or Biden) appoint her successor.  Is it not honorable to play by the same set of rules that got established 4 years ago in the wake of the Merrick Garland nomination.  Do we not want our children to understand what honor is all about?

Likely I am a naïve eldering citizen, but I can’t help but hope that HONOR at this moment in time reigns supreme (no pun intended). I feel it is my duty as a physician, as an emotional healer, and as a fellow citizen to stay grounded, to value virtue and honesty,  to teach our children that in spite of our differences we share a belief system that gives due justice to ALL, and to recognize that with national grieving of our fallen heroes we bestow on each other all the best that we have to give.
[Sept. 2020]

Musings from the Front Line
(comments on what's new and trending in my professional world)

I was heartened to see that the American Academy of Pediatrics has issued a strong position statement firmly denouncing the use of spanking (or any corporal punishment) or verbal shaming or humiliating children as a discipline technique.  I urge you to follow the link here to that article that articulates the sound thinking and reasoning behind this position statement. See AAP News, Nov 5, 2018; "AAP policy opposes corporal punishments, draws on recent evidence" author: Robert D. Sege, MD, PhD, FAAP

However, I do think it behooves us to ponder on why spanking has been so ubiquitous and broadly used over time, esp. those of us of a generation where it was common place.  In so doing, I think it provides a context for moving on and relinquishing what we now know has negative short and long term consequences.

When I read recommendations around discipline it is all very cognitive and “heady”.  It is methodical, measured, and so neatly contrived. There is not usually much about feelings or affect except as a coda to suggest that all parents get angry at their children so “don’t feel bad if you do”.  It is my contention that affect is a critical component of delivering an effective “lesson” about danger, inappropriate behavior, or willful oppositionalism to your children. There has to be a kind of “sit up and take notice” or “I mean business” component to the intervention which is where parental anger along with raw fear can be recruited.  I now think most children (and clearly every developmental stage is a bit different) barely look up from their devices when their parents are droning on with an elaborate sensible set of explanations or prospective consequences. Their attention has to be hijacked emphatically if the intervention is to be meaningful. I think this is why spanking has seemed so effective to many parents because it instantaneously works at grabbing attention.  

So that leads me into thinking about “grabbing that attention” in some less traumatic way.  I have rules in my office and expectations about how children behave. Believe me they know it when parents are helpless to get them to comply.  It requires my recruiting my own anger and frustration in a no nonsense kind of way. They may not always get it the first time, but is infrequent that children come back for a 2nd visit and don’t remember.  They may be a little afraid at first, but many of those kids grow to really respect me and even like me after a time. This is not to suggest that what I do is even remotely connected with the challenges of parenting (esp. a difficult or developmentally challenged child), but it is by way of promoting affective and real anger responses that are developmentally appropriate.  I often coach adult patients on “finding their angry voice” which means not screaming histrionically or irrationally exploding in anger, but learning a more measured, but certain way of speaking our anger. In the same way, I think parents have to find that “angry voice” that is just at the edge of threatening that creates a real memory engram in children’s psyche. There has to be both a thoughtful cognitive delivery but joined with an affective valence that “marks” the experience.  After all, you are not only working to deal with whatever momentary battle is being played out, but trying to help a child integrate and internalize something that they can call up the next time. When it happens again you can thoughtfully and directly remind them “let’s not have to replay the unpleasantness” from yesterday or last week, and if there has been a true affective marker laid down in memory, they will get there quite easily. Ultimately we hope they can internalize and then own more appropriate behavior.  My mom, who utilized corporate discipline in an extremely sparing way, used to go to the kitchen drawer where the pancake turner was stored and rattle the drawer open forcefully, and that was all it took for us to say….”I’ll be good….I’ll be good”. There was a juxtaposition in our memory of her meaning business and we knew it the instant that drawer rattled…..we had “crossed the line”…”her line”…and we remembered without her ever having to use it again.

How to make this work is clearly a complicated enterprise, but I think it’s important to transcend purely cognitive strategies in meeting out discipline and learn to harness and embrace the anger and frustration that comes with the territory of parenting.  Parenting classes can be useful, but psychotherapy can be a useful tool in the service of better embracing and channeling anger. Freud spoke of the “id” the “ego” and the “superego”. Still meaningful constructs for us to understand the complexity of our own psyche and how healthy development guides us toward integration of all of these components.  Slight digression here, but have to get my salute to Freud in here somehow!

Whither Family Therapy

My retirement has opened up channels for thinking about things that used to seem second nature but have become dusty and underappreciated. One of the things I was so enamored with in the 1980’s was Family Therapy. We didn’t have the medical tools we have now (before SSRI’s and Atypical Antipsychotics) and we were more or less forced to apply other models for understanding and recovery.  However, it was so easy to be seduced by the power of drugs (and they truly are powerful) and then imagine all the interventions heretofore were naïve and uninformed. It made me really embrace neurobiology as an essential component of healing that as a psychiatrist  I was in a perfect position to deliver. I feel I became proficient at it and was ultimately a good diagnostician and good medical provider. Psychiatrists owned their roots as physicians and became once again “legitimate”. Now, more than ever, I truly see that it is really only part of the picture.  Weaving child development and family dynamics into any families presentation is so enriching. So many parents feel hamstrung by all the knowledge base that has been disseminated so thoroughly through the Internet, Print Media, and the ubiquitous Broadcast TV. They learn not to trust instinct and common sense in favor of expertise.  It sets up strange dynamics in families that begin to influence things in a negative manner.

I really want to give a shout out here to the efficacy of family therapy.  There was a time when we gathered all the players in the family together and just talked with them and tried to understand how they ticked.  We figured out that parents were easily split by children, by their parents, by their own internal conflicts and remnants from their own experience of being parented.  We understood that child development was a separate thread that wove its way through the family system. We didn’t pathologize or categorize behavior but really tried to figure out its meaning for the system.  We understood paradoxical interventions as a way of capitalizing on the adaptive components of any particular “symptom”. We were likely overzealous in our belief that altering the family system lead to change in an individual’s psychopathology.  But it still held value and contributed to more adaptive functioning, the goal of most of our efforts with both medical and non-medical strategies.

I’m not sure what this means for my practice now.  As I ease out of the world of insurance reimbursement, I realize that a lot of my thinking was influenced by the apparent efficacy of medical intervention as perpetrated by the insurance carriers and the pharmaceutical industry (a whole other discussion).  Medicine pays for a lot of salaries: sales reps, researchers, pharmacists, and all the support staff that their products require. That said, I would be the first to acknowledge that SSRI’s literally changed the landscape of managing anxiety, depression, and obsessive rumination.  It is truly transformative for individuals and it gave me great comfort to see such impressive “results”. But people are embedded in systems: the family, our colleagues at work, our neighborhood, our community, and on and on.

When one of the cogs in the wheel is altered it effects how the wheel rolls.  Recognizing this is critical in coming to terms with how change in the individual gets integrated into the broader system.  Having an anxious wife who is suddenly not nearly so anxious, changes a husband’s role from a necessary agent of comfort and perspective to what?   It’s so critical to understand that this upsets the marital balance and a new equilibrium has to be found. Children who walk on pins and needles around an anxious parent, no longer have to do so, but may be mystified that old scripts are no longer necessary to follow.  Giving voice to all of this is part of what family therapy is about.

As I meander my way through this stage of re-invention, I want to salute all of the pathfinders in family therapy, like Minuchen, Bowen, Whitaker, Haley, and my original mentor at the Menninger Foundation, Art Mandelbaum.  I want to bring more of this understanding back into my practice and be something more than a prescription pad. I do think more than most psychiatrists I have used this lens to evaluate and treat most of my patients over the years.  Nonetheless, I think it needs to be more than noise in the background, and I am hopeful of integrating this more into my new practice. Hopefully others will find the courage to step out of the expected frame and insist there is a system complexity that needs to be evaluated and treated right along with individual psychopathology.  


There was a wonderful op-ed piece in today’s (April 23, 2019) New York Times by David Brooks on Rituals and their role or lack thereof in our culture.  He advocates for upping the ante on rituals as a part of tradition, custom, and the creation of meaning in our lives. I often talk to my patients about rituals in family life as having a centering and grounding purpose.  So many rituals are tied to religion which is great, but for those not inclined to express or believe in this, it creates real gaps in family life in the observance of ritual.

Having just “observed” the confluence of Easter and Passover this year when the dates were so intricately tied together, I was struck by the convergence of Christian and Jewish ritual into one weekend celebration.  I am a spiritual human being, but not especially religious per se. Yet I so enjoy the ritual of Passover and all the centuries of tradition that flow into it. Over all I find Jewish ritual to be almost intoxicating.  Having been raised in a traditional Christian household whose church was community based and people oriented, but had drummed much of the ritual that you might find in Catholicism out of its practice. I treasure and value this experience which was not filled with guilt and shame as I think it helped to solidify values in a very honest and sincere manner.  BUT, I am so inspired by the ritual of other religions. I worked in an Orthodox Jewish Community Mental Health Center when I first started practicing psychiatry in New York City now 40 years ago. It was here I honed my understanding of Judaism and all its ritual. At first, I was a bit incredulous with the primitive way it treated women, and while it is still a concern, I came to find all the rules and strictures so helpful to the people who lived it.  It can be so comforting for people not to have to think about or decide everything for themselves. Getting swept up in the expected mode of being helped so many of that community stay sane in a time of real upheaval and social change in the City. Granted it tied people in knots at times, but I came away from my 10 year encounter with the Orthodox population with a profound respect for its culture and ritual-filled focus. Here in Richmond I had the wonderful experience of being a partner in a practice with a brilliant Jewish man who shared with me all of his experiences in a highly reformed synagogue.  I watched his children at their Bar and Bat Mitzvah, I sat at the Passover table, I heard him complain mightily in the midst of the fast at Yom Kippur, shared in the joy of Rosh Hashanah, and observed his daughter’s marriage under the Hoopa. It tied his family together in a way that was cherished and beautiful to experience.

So many families in this era, however, do not have these rituals.  Nothing to tie children to tradition or something that is bigger that any of them.  I think it tends to nourish narcissism and isolation……two very bad trends in our culture and as such in family life.  Birthdays have ritual but it is very self-focused. Christmas has become a pagan exercise in giving and getting. Graduations provide some level of ritual, but little kids are now “graduating” from Kindergarten with elaborate parties.  It just doesn’t seem the same. I don’t have a good answer, but I think it behooves parents to think about how they build in some kind of ritual. I had a ritual with my younger sister’s children that when they turned 13 years, they would get on the plane in Sioux Falls, South Dakota and fly to Richmond where they would spend a week with Uncle Steve.  It isn’t complex but it helps children advance and yearn for another developmental stage that provides some autonomy and independence. Learning to drive and getting a license can be a family ritual. Celebrating the first time your child can vote provides ritual, but might also create a climate of expectation as to their role as citizens of this city, state, nation, world.  Every parent must find these moments of shared vision and experience that provides a framework that is solid, immutable, and reassuring especially as young people struggle with confusing expectations and a sea of possibility that can be daunting if your internal structures are in flux. Children/and more so adolescents often scoff at these efforts and will/can belittle one’s efforts, but they really don’t know what’s good for them (a common theme in my advice about parenting).  Don’t be daunted by their rejection and ridicule. As we often say, “they will thank you some day”. It can be as simple as taking a moment with just you as parents and all your children on their birthdays (when the gifts have been opened and parties done) to sit with them and say “seriously” what joy it was when you came into our life and what your life means to us is so important for who we are as a family. Without you we would be missing (whatever that child’s magic or special skill set might be).  Without you we wouldn’t look forward to our nightly snuggles and being able to read and teach you. Obviously this cannot be “canned” but has to be your ritual for expressing your love and affection for this child who you gave birth to or adopted or whatever place they have in your life on their day. My parents developed what I now see as a ritual that Friday night was “kid’s night”. We got to pick the menu for our stay at home evening and then all played games together of our own choosing. Granted times were much simpler, but it still holds sway as one of the unique things we did as a family together. To this day when we get together we play games together in this fiercely competitive manner that owes its roots to that Friday night ritual.  (And I still beat my sister at Scrabble most of the time!).

I urge you as parents to work at creating ritual in your family life.  If it is religiously grounded that is in some ways easier and clearer to embrace.  I would contend, however, that creating your own personal family rituals may ultimately have more power and meaning to your children that they can identify as unique to their own family. It  makes one feel a sense of unique grounding and belonging in that essential web of connection that gives us all the best possible start in life.

When Families Lose Their Dog

I have had the recent experience of having 2 different families lose their dog under very different circumstances.  I have been struck with my own reaction to the losses, but also have given witness to its impact on each of these families.

Lucy was a golden retriever who lived next door to me and after 13 and ½ years developed an untreatable sinus cancer and had to be put down.  She was one of those dogs that was loved by her family and who had a special place in my heart.  She seemed genuinely fond of me and would even whimper and bark when she was in the back yard and could hear me or sense me in my garden on the other side of the fence.  I was impressed with the way that the family joined together to all attend to her final moments and they all had a chance to prepare, say their goodbyes, and even take pictures the night before it happened. 

Riley was a Westie that was part of a good friends’ family but who died in a horrific freak accident in which he drowned in a neighbor’s pool.  The circumstances are not what’s important here, but the sudden and inexplicable loss is what has been so profoundly impacting.  No chance to prepare, to say goodbyes, to reflect on the wonderful life he lived and how much meaning he had for not only the family but those people who saw him daily and lived life with him.  The loss seems immeasurably more difficult under these circumstances.  It is impossible not to attach blame and express anger and rage fulsomely when it occurs in this way.  Yet, in the end it is still a loss to manage, to process, and to hopefully come out the other side.  The goal being to recognize all the good feelings he generated and what meaning he had to so many people even if ultimately his life ended in an “untimely” manner.

How families cope is clearly impacted by the reality of loss, but the circumstances are even more compelling.  Dogs have so much more meaning and are so integral to family life than they were when I was growing up.  They are not “children” obviously, but in many ways, they are a much more critical part of the family than not.  We had a “mutt” in our family growing up whose name was Freckles.  I am almost embarrassed to think now how we treated him and how he was just a “dog”.  When it was time for him to be put down, my older sister was given the task of taking him in as she was least connected and emotionally involved.  I can’t even believe now that she was in later high school, but took him away and we never saw him again.  She shouldered this task heroically, but we hardly even acknowledged how difficult this might have been for her.  I can’t remember any kind of ritual or way in which we as a family even noted the event.  I am not confessing, per se, but rather I think it was not atypical of dog owners in the past to not attach such meaning to their role in a family.

Back to now and the loss of these dogs.  They both provided a kind of solace and companionship.  Coming home was not to an empty house, but to a dog wagging their tails, yapping/barking in excitement, and providing amazing comfort.  Every family member was on equal footing.  No one was “younger” or “older” or “more accomplished at this or that”.  Everyone had an equal stab at the affection and care they provided.  Grieving this loss can be profound and intense.  It no longer seems inconsequential, but is a real hole in the fabric of a family’s composition.  Neighborhood walks no longer occur in the same way.  Rituals of care and routine are gone.  It just seems important to underscore that these is an intensity of grief that is important to respect and honor.  It takes time to grieve and to heal from loss.  For children it may be the first exposure to death and loss.  It is both a challenge and an opportunity for you as parents to teach them about grieving.  Is there a “doggie heaven”, why did this happen, struggling with tearfulness and watching you as parents show compassion and grief in your own way.  If you are not blinded by your own grief, it can be an opportunity to model emotional expressiveness. It can in some ways prepare children for more profound losses such as grandparents, friend’s parents, even other children.As fellow travelers here, it is incumbent on all of us to be sensitive to how these losses impact in real and measurable ways.  “It is just a dog” can so trivialize what for many is the loss of one of their most immediate and tangible connections.  Be respectful of people needs to both talk about it and other moments be silent.  I often think of grief as like waves on an ocean beach.  The emotion washes in and overwhelms us and then it washes out and things are just fine.  You might catch someone who has lost their dog when the waves are in or out. Just because it is out, doesn’t mean it won’t come washing back.  Obviously, there are more profound losses that we all experience, but I hope that I can increase sensitivity to the real impact the loss of a dog can have on family life.  Even as just a friend and neighbor to these 2 dogs, it has impacted me in ways that I really didn’t conceptualize previously.  It adds another dimension to my understanding of just how important dogs can be in maintaining the fabric of family life.

School's Out: Now What??

I’ve been listening to parents talking about the end of the school year and it is always interesting to hear the range of concerns, worries, excitement, and relief that this seems to generate in families.  In our highly scheduled and structured lives, helping children, adolescents, and parents make the transition out of the school year into the summer can be a complex task.  It provides both opportunities and challenges that if thought through will ease this experience for everyone involved.

First and foremost, you have to survive the end of the school year.  This may mean studying for exams, getting make up work done that has been avoided until there is no more time to avoid, or confronting possible failure and need for summer school or even repeating a grade if necessary.  All of this can be fraught with anxiety as parents sometimes work harder at this then their children.  This is a whole other topic and I will not elaborate here on managing this struggle.  You as parents see the consequences of inaction more clearly than your adolescent might.  Because of this last push, everyone may feel exhausted and even dispirited by the time the school year comes to a close.  There is also a propensity for teachers and students to be depleted by all of the demands on them administratively as well as hopefully all parties desire to reach a “successful” close to the year.  SOL’s may be completed and suddenly there are days of movie watching or other “fun” activities that one envisions as a kind of “marking time” until the official end of the school year.  There are graduations to be celebrated which entails a whole other level of effort and engagement.  The complexity of the school year ending is wide and varied.  Endings may be experienced very differently by each individual.

Because of this push and the effort entailed, parents and students my approach the last day with glee that they are now “free” and unburdened of further challenges.  Yet, I would protest that it is not a great idea to simply let your structures and expectations come crashing down without thought or planning about the needs that children have.  While I strongly advocate that children need some free time and opportunity for “down” time, I also think in our current culture too often this means sitting in front of screens and passively engaging in trolling the internet, watching You-Tube blips, or being consumed by Netflix shows, etc.  Reflecting back on another time (my youth) it provided opportunity for free play, joining neighbor kids in self-directed activity, and creatively managing time.  No one “structured us”.  We created our structure and with some bias, I think this had great advantage from a developmental perspective. Mother’s shooed children out the door early in the morning and other than eating and bathroom breaks, we played outside.  Obviously, this was another era in which safety concerns were not as challenging and knowing all the neighbors was a common experience.  I do understand it is different now, but how to recapture some of this free-spirited play and allowing children opportunities to be creative remains a critical task.  Too often I hear that children feel “bored”.  They look to the adults in their lives to provide excitement, interest, and amusement.  They are passive in this process. When adults take over and lay down structures externally without engagement, it only promotes this outcome.

From this follows my recommendations that children (and adolescents) should be engaged directly in planning for the summer.  They need to generate ideas of what might interest them, what camps or learning programs might be available, how they see the balance between structured activity, down time, family vacations, summer jobs, and long hours of sleeping (esp. for adolescents).  Often times, there will be push back.  Obviously, more push back from older adolescents.  Setting clear expectations about “meaningful” activity is critical.  Sketching out a calendar of the summer can be useful.  Getting them to work with you on what they can do and when they can do it is essential.  Parents typically have a calendar of their own, but I think it is important for children to see this in black and white too.  Engaging them builds ownership of the planning and when the time comes for some activity. They will resist less about getting up in the morning to get to a camp, weathering the storms of disappointment if an activity does not meet expectations, or finding that whatever they chose is “too hard” or feels “just like school”. 

Obviously, some of the planning has to be done earlier than NOW.  Special camps fill up, parents work schedules have to be coordinated, custodial parents yield weeks of time to the non-custodial parent, financial resources may be limited, etc.  There is no one right way to go about this, but putting some thought into the whole of the summer can be an opportunity for families to “develop” together.  Sitting down with everyone involved, particularly in divided households, can be enormously beneficial.  Children who see the buy in from both parents are grateful.  It provides modeling for cooperation and developing flexible strategies that may require everyone stretching themselves in some way. Ultimately if all involved family members are truly engaged there is more success in reaching the planned outcome.

Truly balancing down time and engaged time can be a complex enterprise.  Too much engagement can be stifling. Too much down time can corrupt children’s capacity for growth and learning “non-academic” but critical life lessons. In the end there is no one right way.  Every parent and every child need to find “their” way.  In the long run what is critical is not letting these opportunities and challenges slip away, but to be thoughtful in addressing the task, whatever the outcome.   Summer vacations in this measure simply provide more grist for the developmental wheel.  Good luck.

My Child is Gay, Lesbian, or Transgender—Now What?

This week marks the 50th Anniversary of the Stonewall riots which was a turning point in our cultures march towards acceptance of divergence in sexual orientation and/or gender identity.  For those parents whose child identifies in this way, it can be an arduous and challenging journey to figure out how to respond to and integrate this reality into family life.  I chose not to recapitulate in this forum all of the research and data that has emerged in regard to solidification of sexual orientation and gender identify at a very early age, but rather focus on the emotional process of coming to terms with whatever reality your child brings to the table.  I think it important to set religious and cultural values aside in this discussion as I would prefer not to be an advocate for any one frame of reference, but rather think as a clinician when I am confronted with families facing these concerns.

Clearly times are very different now than when I completed my specialized training in Child and Adolescent Psychiatry, now more than 40 years ago.  AIDS had not even reared its head, transgender was a term that was esoteric and remote, words like “binary” and “cisgender” where not even part of our vocabulary, and same-sex marriage would have been unthinkable. To see this evolution of thought, belief, and science change so dramatically in this time has required a sophisticated and challenging process as one deals with (primarily) adolescents and parents around this struggle.  Bullying campaigns to some degree have been an effort to protect sensitive and “weak” children from oppressive and scary experiences with their peer group.  While not all children who are bullied have sexual orientation or gender identity issues, this is a group particularly targeted by their peers at least from a historic perspective.  As such, many parents have already had some experience with their particular child being targeted as “different” or as we might now say “non-conforming”.  More parents have a knowledge base from which to react and help their children who may be coming to terms with who they are.

It may be a bias, but I think there is an almost universal desire on the part of parents to hope your child is solidly heterosexual.  This is not from a values standpoint, but rather with knowledge that their road may be more complicated, challenging, and filled with a level of emotional intensity that their journey may require.  While we have come a long way in terms of general acceptance of divergence, I believe it is still a harder road for them to travel.  Who would want that for their child.  I lay that groundwork, as I think it is important for parents to be accepting of their own disappointment that they/their child will have this more difficult journey.  How to bind this disappointment is the ultimate challenge in helping your child come to terms with who they are.  I remember so clearly that when my nephew came out to my sister when he was in his early 20’s by telling her he was dating a “man’s name”, she took a deep breath and said: ”What would I say if it was a woman?  I’d ask about her, find out who she was, how they met, how long they had been dating”.  She then tried to do just that with his boyfriend.  I always thought she was so incredibly cool about how she handled it.  I recognize this is very different if your child is 12 or even younger when dealing with transgender issues as well.  Keeping you cool and striving not to be reactive or overwhelmed emotionally is particularly challenging.  I know that developmental contributions are not so much considered anymore, but we used to mark adolescence as a time of experimentation, trying on different identities, sometimes to shock, other times because that is in the nature of the development of identity.  In this measure, not all children/adolescents who assert they are gay or transgender hold these identities into adulthood.  That is not to engender “wishful” thinking as I think it is not the usual trajectory, but rather to appreciate that your negative responses can drive all of this underground and make it an even more compelling direction for some.  We know that adolescents will sometimes do exactly what their parents forbid them to do……just to be contrary.  I still adhere strongly to a developmental model and at times this may put me at odds with the current thinking that identify is “always” set from a very early age. 

My adage is to be cool and measured in your responses to these developments.  That your child feels safe enough to talk to you and reveal themselves to you should be considered a great tribute to your parenting.  It becomes more complicated when kids are “outed” by friends, siblings, or (hopefully not) violating their messages, emails, or other social media accounts.  Knowing that you know can be a cumbersome issue if not dealt with in some open and meaningful way.  Letting children know that you love them unconditionally at these moments becomes critical.  Providing some space for open discussion and inviting them to talk and to share these struggles is immensely important.  Helping them to see that you can accept who they are and where they are headed will go a  long way towards their journey becoming less arduous and fraught with conflict.  Understand that while they may seem self-assured, typically there can be shame and self-doubt that pervades their sense of self.  They may harbor the same biases and prejudices that much of our culture has expressed for so many years.  I emphasize that it is a process.   They are processing and coming to terms with this and you too as parents will process and come to terms with it.  This typically takes TIME.  It is a seldom a one moment in time kind of enterprise.  It may have to be digested again and again, hopefully with greater clarity and comfort as TIME passes.  Don’t be disappointed if it takes you TIME as a parent.  As long as you have the ball on the end game, i.e. acceptance of your child for who they are, you can take as much time as you need.  Parents can find support with therapy, with organizations such as PFLAG (Parents, Families, and Friends of Lesbians and Gays) or other community-based institutions (even religious organizations and schools).  Don’t be shamed by your need for guidance and support.  It is not always comfortable and may even challenge your own belief systems.

I strongly advocate against recruiting others to “change” or “dissuade” your child from this reality.  Conversion therapy is no longer condoned by most professional organizations, at least in the state of Virginia.  Conversion therapy again and again has been shown to be ineffective in its goal and contribute further to a child’s sense of shame and guilt.  You can be real and upfront with your own struggles with it, but always in context of doing whatever you can to make your journey towards acceptance the priority.  It behooves no one to shame your child or make them feel less than whole.  Transgender youth pose a particular challenge for many parents as it is still less understood, accepted, and still stigmatized.  Nonetheless, you can express your reservations and concerns in a thoughtful way, without further traumatizing them. You can empathize with their struggle without solving it for them.  It is especially here where professional guidance and help may be critical.

If you’ve behaved poorly and emotionally, be strong enough to own it and say “I was wrong”.  Just because you messed up initially doesn’t mean you can’t still “right the wrong”.  Own that it is a hard issue….one that you weren’t well prepared for but now you will do everything in your power to make it up to them.  Share with them your journey and be comfortable that is a process for you as much as for your child.  While they may not be ready to immediately forgive you, it will start you on the road to that endpoint.  Modeling evolution of thinking, feeling, and belief is enormously powerful contribution to your child’s development.  Evolving is a good thing.

This is in no measure a comprehensive guide, but rather my usual musings on a topic that has particular resonance this week as Rainbow flags fly and Proudly Gay, Transgender, or Lesbian comes at us from all corners of the media.  I underscore that you will be traversing complicated territory as you do your best to help your child feel comfortable with who they are.  Root out issues of self-blame. We are certain that it is not parenting that creates divergence, but rather divergence is rooted in neurobiology that is a given as much as one’s athletic prowess, intelligence, and stature.  It is compassionate parenting, however, that can make this journey a less arduous one for your child.


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last updated: May 23, 2019
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