Thursday, June 22, 2023

Speaking Up: Strategies for Discussing Your Symptoms with Your Psychiatrist

Over the course of the pandemic, I noticed an increase in clients seeking psychiatric consultation for the first time. Whether they'd been in therapy for years or were just starting their forays into the world of mental health, lockdown combined with increased demand made it difficult to schedule appointments and even communicate with psychiatrists. While a lucky few are able to find something that works pretty quickly, most clients end up going through multiple changes before settling on something. Even outside of work, I've noticed friends find a psychiatrist, get prescribed something, and stick with both, even if they don't work as well as they'd hope. It can take time to find the right medication and the right dosage. As tempting as it may be to take matters into your own hands, I always recommend clients be clear and honest with their providers about what has and hasn't been working.

Of course, this is more easily said than done.  It can be difficult to explain things like emotional and cognitive symptoms to anyone, much less a doctor or other healthcare provider, who may use completely different language. Often times, we're being asked about symptoms we've experienced for as long as we can remember, so the thought of rating severity on a 1 to 10 scale can feel confusing to impossible. Even if our symptoms are worse than they've ever been, it can feel disingenuous to say we're at a 10, because there's always the voice at the back of our minds telling us that someone else has it worse. Further, there can be a pressure to say the right thing, or a worry about what we’re “supposed to” report. As a result, I've noticed clients often under-report symptoms, or downplay their severity. Someone might tell their psychiatrist the new medication is "working alright" if they feel it's helping a little, but not enough, but if the psychiatrist thinks this means all is well, they may respond by saying no change is needed, even if the client is dissatisfied.

In any instance of miscommunication, my first thought is to check on what kind of language each party is using, and how they use it. In the prior example, the client is using the word "alright" to mean "some but not enough", while the psychiatrist assumed it meant "well". If this were a close personal relationship, I'd recommend discussing the use of language, or spending time clarifying what is meant. However, psychiatric appointments are often quite short. Thus, I tend to instead recommend clients change the way they talk about their symptoms. Describing their symptoms and experiences in more precise ways can help clarify the level of severity of a client's symptoms. This can also give the psychiatrist a better sense of what to expect -- a psychiatrist who knows your symptoms are moderate rather than mild will know that the lowest dosage of the first medication they start you on might not be enough.

The first piece of this is to quantify your symptoms. While using 1-to-10 scales works for some, this isn't the only way to do this. Frequency and duration are the two primary ways of keeping track of this, and are often part of the diagnostic criteria when it comes to judging severity of symptoms. It also helps to be specific about what subcategories of symptoms you experience. For example, one client may describe their insomnia by stating that it takes over an hour to fall asleep more nights than not, while another might say that they wake up 3 to 5 times each night, about 5 nights per week. Both of these reveal more information than just saying "I'm having trouble sleeping", and give useful background that can help narrow down approaches. After all, if the person who keeps waking up in the middle of the night wasn't specific, they may be given medication and advice aimed to make them sleepy at bedtime, which might not help ensure they don't wake up an hour or two later! Similarly, clients who have panic attacks often describe physical symptoms that come with them, like an increase in heart rate or sweaty palms. However, these symptoms look and feel different for everyone, and this can impact what kinds of treatment a professional would recommend.

The second piece is to measure the impact on your day to day life. Some of this includes quantifying symptoms as mentioned above, like by tracking how much time it takes you to pull yourself out of an anxiety spiral. But impact goes far beyond the time it takes to self-soothe, and often gets at the reason we decided to seek services in the first place. If a new medication makes it easier to keep up good habits and get chores done, it's worth noting, even if you're only part way to reaching your goal. If you struggle to leave the house, taking a medication that makes doing this possible once or twice a week is still better than nothing, and further, is proof of concept that it's possible to get to a point where leaving the house daily is a viable goal.

If your symptoms are hurting your productivity at work, personal relationships, or even just your ability to enjoy life, it's worth being clear with your doctor if the medication they're prescribing isn't helping, or makes things worse. This is especially the case when it comes to side-effects. If you're taking medication to alleviate symptoms of depression that come up in your romantic relationship, having those depressive symptoms replaced by anger and irritability at your partner isn't a viable solution. Even more internal, harder to quantify symptoms can get in the way of our day to day lives.  Having thoughts we can't ignore can make it harder to be present in our day to day lives, and even if we can't realistically track exactly how much time we spent thinking about something, we can still communicate whether these thoughts resulted in us missing a meeting that day or if we got less work done all week.

It’s worth noting that there are many people who experience symptoms but sufficiently manage to cope with them, such that they underreport, and may even fail to qualify for a diagnosis. The "but I have a system" answer fails to account for the fact that if you need a system to manage something like timeliness, then timeliness is still a problem, even if you already have the solution. Further, often these solutions require extra work. If you spend 15 minutes every morning double checking the locks on your doors so you’re not anxious about it later, that’s still 15 minutes of your life you won’t get back.

Even if you're theoretically able to track your symptoms, it can feel difficult to find the right words to describe what's going on for us. Mental health can be full of jargon, and many clients of mine have expressed confusion over what kinds of terminology to use. Most psychiatrists will have an intake questionnaire new clients fill out when you first begin working together, and often, these can be a good place to search for phrasings that both fit your experience and their clinical understanding. Part of the purpose of the intake is as a jumping off point to start a conversation about your symptoms, so if a question is asking about a symptom, but isn't quite phrased right, it's worth bringing this up to your provider as well. For example, many ADHD questionnaires ask if you feel as if you're "driven by a motor" as a way of checking on hyperactivity. Of course, many people with ADHD experience hyperactivity, but would describe their experience of it differently. Another useful part of looking through these questionnaires is that we may find symptoms we never realized were connected. I have had a number of clients who never realized their physical panic attack symptoms were different from general anxiety until we discussed them in session! Common questionnaires include the PHQ-9 and the Beck depression inventory.

If you have good rapport with your psychiatrist, you may find using consistent metaphors helpful, especially when it comes to examining changes in symptoms as they correlate with changes in medication. While less quantifiable language can be vague, it can also be easier than tracking and quantifying, especially for emotions and other symptoms that are less concrete. Some metaphors are generally well understood, such as those involving weather; a depressed client saying they had gone from "a downpour to a light drizzle" would effectively communicate improvements in their mood, while also clarifying that their symptoms were not entirely gone.

As mentioned above, tracking can help with measuring changes in your symptoms. Many clinicians will have clients take the same questionnaire months apart, to help monitor these changes, but you can easily do this at home, too. For more subjective descriptions, journalling can help a lot in tracking your thoughts and feelings in the moment. This is especially helpful because it can be hard to fully remember what something was like days or weeks ago by the time your appointment comes around. I have many clients who will highlight passages from their journals to read to me in our sessions, and it can really help show what a moment of panic or depressive spiral looked like, even if they're fine in session. This can also help with changing medications, as you can find excerpts from before and after a change, and look for patterns in thoughts, emotions, and behaviors. You might notice that since a change in medication, you've stayed at work for longer, had fewer intrusive thoughts about your ex, or just generally felt more positive about your life.

Lastly, I want to make it clear that communication is a two-way street, or at least it ideally should be. If you are having trouble communicating with your psychiatrist, I'd definitely recommend talking to them about it first, as they may have some ideas on how to fix things. However, that doesn't mean you have to stick with a psychiatrist who isn't working with you. Listening to you as a person is a psychiatrist's first job in treating you as a patient, so if they're not listening, they're not doing their job. Don't be afraid to look for someone else. I often say that looking for a therapist can feel like dating, in that you often have to talk to many people to find a good fit. With how many psychiatrists involve therapy in their work nowadays, this seems especially true for them as well.

Monday, June 13, 2022

What type of therapy is best for you?: a theoretical model breakdown

The search for a therapist can be long and full of jargon. Resumes have lists of trainings, websites have unfamiliar acronyms, and even Psychology Today has a section for treatment approach. Most will try and guess the meanings from context, skim Wikipedia pages, or skip over these altogether. Still, clients and friends alike ask me how to tell what theoretical model is the best. And, as with so many things, my response is: it depends on who you are and what you're looking for.

For starters, I often find it works best to find a model that operates differently from how you naturally approach problems. For example, if you tend to take a very direct problem solving approach, seeing a therapist who mostly works from a solution-oriented model might feel redundant. On the other hand, you don't want something so far out of your comfort zone that it isn't doable. Therapy may feel like work, but it should be the kind of work you're willing to do. Some people care a lot about the research and evidence behind certain theories and techniques. In my breakdown below, I'll start by talking about the most common and most evidence-based models, before going into the rest. It's worth keeping in mind that just because a model isn't evidence-based doesn't mean it isn't going to work! Some of these are harder to research by nature, some struggle to get funding, and others are too new to have much research behind them. My advice is to not let whether something is evidence-based or not put you off. You may find that what works for you in therapy is very different from what you'd expect.

Cognitive and Behavioral

The most evidence-based model is Cognitive Behavioral Therapy, with related models like Dialectical Behavioral Therapy closeby. CBT's numbers-based system for evaluating emotions makes its results easy to quantify and therefore study. CBT examines the way our thoughts affect our emotions, which in turn affect our behaviors. This can work well for people who get so stuck in their emotions that it's hard to look at things more logically. However, since CBT is so commonly used, there's a good chance that those who have found therapy unhelpful have encountered this model before. Many clients with previous therapy experience have said that therapists suggest things they already do, like reframing negative thoughts, or writing a list of pros and cons to make a decision. CBT works well enough for standard levels of anxiety and depression, as well as circumstantial stressors. However, if you're dealing with more complex issues such as trauma or addiction, I'd highly recommend finding a therapist with training that applies CBT to your specific issue. 

A couple of related models build on the CBT framework. Mindfulness-Based Cognitive Therapy adds mindfulness to cognitive work, both as a way of better noticing thoughts and feelings, and as a way of approaching them nonjudgmentally. If these are issues for you, mindfulness might help. Mindfulness in general is a concept therapists use in many different models, but you probably most often see it named as such when incorporated into theories like this. In Dialectical Behavioral Therapy, mindfulness is foundational. Though DBT also builds on CBT, it focuses less on reframing thoughts and more on regulating emotions. While CBT works well on its own for those whose problems are more emotional than behavioral (depression, anxiety), DBT was created specifically for clients with Borderline Personality Disorder, making it good for those with complex trauma, a pattern of interpersonal difficulties, and high reactivity or impulsivity. However, it's also helpful for fluctuating emotions (bipolar, depression), eating disorders, and substance abuse. This is because it focuses in developing skills that help notice, tolerate, manage, and describe difficult emotions. Basically, DBT teaches clients to build up a sense of internal emotional structure. If you find yourself in crisis mode often, struggle to manage strong emotions, or just want to feel like less of a mess, DBT may be a good fit. It's worth noting that DBT-informed talk therapy is different from a full DBT program at a clinic; DBT programs are more geared to high-risk individuals.


While the CBT-based models focus on thoughts and logic, Humanistic models tend to focus more on emotions. In particular, they focus on a person's individual nature, including their identity and strengths. The simplest example of this is Client-Centered Therapy, where the client leads the discussion and the therapist listens, reflects, and provides support. While this alone can work well for building self confidence and allowing clients to take up space if they struggle to otherwise, most therapists integrate this with other types of therapy. It's worth noting that some see this as part of a therapist's personal style -- some therapists tend to listen and reflect, and others are more directive. Similarly, Solution-Oriented Therapy focuses on setting goals and solving problems. While this can address simpler stressors, it isn't going to help on its own for psychiatric concerns. Like Client-Centered Therapy, it can be used with other theories, or function as a style of therapy.

Other humanistic models are more specific to root causes behind the difficulties that bring clients in to therapy. Existential therapy looks at the search for meaning in life in a way inspired by philosophy. This can help with depression, grief, loneliness, and generally feeling stuck in life. Though philosophy fans may be those most drawn to this, I'd probably recommend it more to people who struggle to examine themselves in this way, since for them this would be an area for growth. Meanwhile, Experiential Therapy uses roleplay and re-enactment to bring the emotions present from past situations to the surface. In doing so, this helps make bottled up emotions easier to see and process, and can work as an outlet. Gestalt Therapy similarly uses re-enactment, but the focus is more on what's going on in the moment. Classic Gestalt exercises involve things like writing a letter or speaking to an empty chair, as a way of getting out and thus becoming more aware of thoughts and feelings. In contrast, an Experiential exercise might involve art, acting, or guided imagery, with the focus on a particular past event and the associated emotions. The different focuses mean they work for different issues, with Gestalt working well for things like anxiety, depression, and grief, while experiential works for trauma and behavioral issues. For those who prefer traditional talk therapy, these models may push on or expand comfort zones, with Experiential work straying a little further from the typical two person conversation. And, it's worth keeping in mind that not every session is necessarily going to involve one of these exercises. Most therapists will check in about things like level of comfort and willingness to do certain exercises, since we understand they can feel strange, vulnerable, embarrassing, and a little silly. However, if you enjoy self-exploration, there is a lot to gain from expanding your comfort zone.

Newer models

As cultural perspectives shift, so too do therapeutic models. These newer therapies are often collectively called Postmodern theories. Often these link to the different ways people see themselves and the world. One example is Narrative Therapy, which works on separating clients from their problems by changing their perspective of self. This idea is very reminiscent of person-first language in that it insists a client is not, for example, "an anxious person", but "a person who struggles with anxiety". The work itself comes from deconstructing the stories we tell ourselves about ourselves, editing how we tell some parts, and highlighting things that may get left out. This ties in with ideas about subjective truth. Issues best fit for Narrative Therapy are usually long term patterns with recurring themes, like social anxiety or apathetic depression. While this model may appeal to readers by name alone, more important is that the model fits in with how the client sees the world.

Another Postmodern theory is Internal Family Systems, or parts work. This theory looks at the self as one that contains many individual parts, each with their own functions. A simplified version of parts work is shown in the movie Inside Out, which depicts emotions as actual characters. However, parts aren't always emotions, and a single emotion can have many parts associated with it. These parts can be wounded, suppressed, or overburdened, and this is where a client's difficulties are seen to come from. However, these parts all have purposes. IFS is called this because the ideal is to have parts that work together, like an internal family, all functioning as one harmonized system. This can work well for anxiety disorders, OCD, trauma, and depression. In particular, IFS can help if you notice having conflicting thoughts or feelings a lot, as this suggests the conflict is between two or more parts. IFS is still new enough that it isn't always taught in graduate school, so if you're looking for an IFS therapist, it makes a huge difference to make sure they're trained in it.

Older models, revisited

You may notice that I haven't covered the father of psychology: Freud. The stereotype of lying down on a couch and talking about your mother is called psychoanalysis, and is far less common than it used to be. More commonly, you'll find Psychodynamic Therapy, where clients are given space to freely speak about feelings with the aim of gaining awareness about emotions, behaviors, and relationships. What it takes from psychoanalysis is the aim to bring awareness to the origins of long term problems, including any related repressed feelings. It's worth noting that traditional psychoanalysis was long and intense, and while some therapists do brief Psychodynamic Therapy, most often treatment is longer term.

Perhaps the biggest revision of an older model is Attachment Theory, which looks at the attachment made between child and parent and how this affects relationships later on in life. Though stemming from older models, Attachment Theory has a lot of evidence and studies to back it up, showing how unstable parental bonds can become unstable relationships later in life. While a more traditional version of this may focus on the client-therapist relationship as a way of learning healthy relationships, many who primarily use other models will call themselves Attachment-based or Attachment-informed, showing that they use the Attachment model to inform their work, even if their actual therapeutic approach is different. Attachment work is most helpful for those with a pattern of relationship difficulties, romantic or otherwise.

Holistic models: beyond talk therapy

As with any field, there are many therapeutic models that are considered more alternative. Though less evidence-based, they can work well with long term therapy and personal work. Therapists can combine these techniques with other, more evidence-based systems. However, it's worth noting that these aren't usually taught in grad school. Some grad programs focus on alternative therapies, but if you're seeking therapy that largely focuses one of these styles, I'd recommend finding a therapist who either went to a school that taught it or has gotten a credential or license in the specific technique. Many therapists will have such credentials listed on their website, but if not, it's worth asking.

Creative therapies are probably the most well known of these. With some basis in psychoanalysis, these therapies use different forms of expression to examine thoughts, feelings, and experiences that clients might not have the words for or find hard to talk about. Because of this, some of these techniques are often used with children, particularly kids who are shy or struggle to put words to their experiences. These techniques are also often brought up in groups. It can be easier for groups to discuss things like art and music, because it feels less vulnerable than speaking directly about difficult feelings and experiences. 

Art therapy, the most well known of these, is the label used for two different techniques in this category. More traditional, psychoanalytic art therapy involves giving prompts and analyzing the results, like having a kid draw a picture of their family. There's also expressive art therapy, which tends to be more freeform, with clients free to depict feelings and experiences in myriad ways, both abstract and symbolic. The therapist may ask questions while you create, like about what colors you choose, or just observe and save discussion for after. Dance therapy works similarly but with freeform movement, sometimes guided by prompts and sometimes using free association. Here the therapist may observe, mirror the client's movements, or draw the client's attention to things like posture, body parts, and breath. Music therapy can involve listening to, singing, or creating music with instruments. The focus can be specific songs or tunes, with discussions of feelings and memories that come up, or on using instruments and vocals to express whatever comes up, and provide catharsis. Though these techniques can feel intimidating, especially for those who don't have creative hobbies, it's important to note that no experience or talent is necessary. Creation here is a way of getting out what's inside, so it can be examined, and thus it doesn't actually matter how "good" the result is.

Another angle often taken up by some therapists is spiritual. Religious counselors can draw from their religious beliefs, ideally if this is shared with the client. The most common I've seen is Christian and Buddhist perspectives. Outside of organized religion is Transpersonal therapy, which addresses spirituality more generally. This looks at things like wisdom and finding meaning, and could be a better fit for those who are more spiritual than religious. Transpersonal therapists see the client as the expert on their relationship with spirituality, so they function more like a copilot than a guide. Transpersonal therapy is more of a lens than a technique, so it is usually very personalized to the client; this can involve mindfulness practices, journaling, breathwork, creative therapies, movement, and more.

The mind-body connection is explored further in somatic therapy. This most often involves noticing how the body responds during psychological work, but can also involve movement, postures, and other experiential techniques. This is often used for trauma work, and can be particularly helpful for those who notice physical symptoms coming up from mental health issues, such as chronic pain. If this is what you're dealing with, it's important to see a doctor first to be sure that the issue isn't medical in nature.

One of the newest alternative therapies is EMDR, which stands for Eye Movement Desensitization and Reprocessing. This involves using eye movement (usually watching something move back and forth) to desensitize traumatic memories and reprocess them, separating out strong emotions and strengthening positive beliefs and feelings. The full process takes place over many sessions and can involve discussing memories, analyzing negative and positive thoughts and feelings, dealing with strong emotions, and noticing feelings, thoughts, and sensations linked with stressors. Though it's primarily used for trauma work, even other diagnoses such as anxiety, phobias, and depression can have roots in traumatic or stressful memories. EMDR is somewhat controversial because its mechanism of action is unclear, but it is highly evidence-based. Many of the techniques used in EMDR draw from CBT, psychoanalysis, somatic therapy, and even some humanistic techniques. EMDR is a complex modality with a specific process, and can involve digging into the depths of the mind, so it is very important that the therapist have the appropriate training and certification.

Multi-modal therapy

Many therapists will refer to themselves as eclectic or integrative therapists. This usually means that they adapt their style to the needs of the client, depending on the problem, goals, and the client's personality. This may include trying different techniques, using specific therapies with specific types of clients (ie DBT for bipolar, Gestalt for grief), or combining approaches to create something new. As a result, it's hard to say this style does or doesn't work for particular clients. Drawing from different sources allows the focus to change as the client's life changes. You can start by dealing with something acute like panic attacks, then move into examining long term patterns of anxiety, before moving on to self-exploration and finding purpose, and all with different approaches. Therapists who practice multi-modally will often list out which modes they draw from the most. If you read this far and found it difficult to choose one, finding a therapist familiar with some or all might be a good call. Above all, make sure that whoever you work with is someone you trust. While trust is important for any client-therapist relationship, drawing from multiple models relies more on client feedback than sticking to just one. In this sense, you need to trust your therapist's ability to guide you, their judgment on what may and may not work, their understanding of you and your situation, and their ability to take whatever feedback you can give them.

Ultimately, the connection between therapist and client correlates with good results in therapy far more than use of any specific theory. A client can't feel safe with a therapist who makes them uncomfortable, and can't be challenged in an environment that bores them. Feeling heard and understood is such a base-level human desire that it can be easy to overlook how much of a difference it can make on the therapeutic process, but on some level, this need is often what drives us to seek therapy in the first place.

Saturday, October 30, 2021

Weird but Healthy: the Addams Family as Relationship Goals

The Addams Family has been a classic TV family for decades, and for good reason. Their strange sense of aesthetics and humor give us something to laugh at, while their genuine love for each other gives us something to aspire to. Strikingly, parents Gomez and Morticia don't have the dysfunctional dynamic many couples in the media do. Despite the stress and conflict they face, their relationship remains solid. So, how can we have relationships like Gomez and Morticia?

Dr. John Gottman is known for his studies on healthy relationships. He and his wife Julie have together created The Gottman Institute for teaching couples therapists how to turn the results of their research into real change for clients. One such tool is called the Sound Relationship House. The idea is simple: a secure partnership has a strong foundation, weight-bearing walls, and levels that the couple can build upon, much like a house. If we examine the structure of it, we can see that Gomez and Morticia have built these principles in how they live and love. Creepy and kooky as they are, the Addams' relationship house is a sound one.

"Gomez, last night, you were unhinged. You were like some desperate, howling demon. You frightened me. Do it again."

The foundation of the house is building love maps. Gottman uses love map to indicate one's inner world, and it's important to know these things about your partner. Likes, dislikes, passions, these are often the first thing you develop in a relationship as you get to know each other. Morticia knows that when Gomez is playing with his trains, it's because he's upset. Gomez knows that Morticia likes dancing with him. They know each other well enough that they can signal a request to the other and with only body language, the other knows what to do. They remember details about each other and each others' lives, like Morticia knowing about Gomez's childhood and him knowing her family.

"Woo her. Admire her, make her feel like the most sublime creature on Earth"

The next level is shared fondness and admiration. Gomez and Morticia make this very obvious, especially in the iconic 90s movies. They're every bit as passionate as you'd expect a young couple in love to be, even decades into their marriage. Morticia speaks French to Gomez, and he speaks Spanish to her (literal romance languages!). In terms of actual love languages, they show quite a bit of words of affirmation as well as physical touch, but they also spend time together and do things for each other (eg Gomez pulling out her chair when she sits). Importantly, these are ways they enjoy feeling admired. In the same way that Morticia would not enjoy being gifted a pastel pink dress, it's important to know if the way you express love to your partner is something that helps them feel loved in the first place.

"His trains are everywhere, the children are beside themselves... this can't go on. How can I help him?"

Of course, it's not all rainbows and butterflies -- or for the Addamses, darkness and moths. Things do get stressful, and when they do, healthy couples turn towards each other, rather than turning away (or worse, against each other). Gomez vents his frustrations about Fester to Morticia, and she attends to him when stressed. The Gottmans recommend having daily 15 minute stress reducing conversations to support each other, and we often see Gomez and Morticia not only having such conversations, but doing anything they can to help.

"What is he, a loafer? A hopeless layabout? A shiftless dreamer?" "Not anymore..."

For a couple of morbid types, Gomez and Morticia manage to keep things light and positive, even in the face of financial and familial difficulty. Couples in healthy relationships avoid criticism and instead see the best in each other. When Gomez is depressed, Morticia is empathetic. Even when Gomez is criticized for his unemployment, she thinks wistfully about how he's less of a dreamer than usual in his depressed state. You never see them criticize each other because they focus on the positive and give each other the benefit of the doubt.

"That glorious cruise. No quarrels. No cares. No survivors."

Conflict is unavoidable, so it's important to know how to manage it as a couple when it comes up. Now, we never really see Gomez and Morticia argue, and thus never really see them in conflict with each other. However, we do see them in situations that are likely to provoke conflict, and the ways they problem solve and get through the hard times. The Gottmans suggest three things: dialogue, self soothing, and accepting influence. Any conflict comes up gets discussed between them, and they have such deep love for each other that it doesn't turn into resentment. When they lose the estate and have to stay at a motel, everyone bands together and does their part. Morticia looks for work and lets Gomez self soothe through his depression. They don't ever disagree on how to tackle a problem, but there are times when each accepts influence from the other, and allows them to go ahead with something they have more experience in. Earlier in the same movie, they noticed when they felt in over their heads and decided to seek help. Morticia turns to grandma for help, and when that's not enough, they're okay with going to therapy for outside support. We see such little conflict between them that I couldn't really find a good quote for it.

"I'm just like any modern woman trying to have it all. Loving husband. A family. It's just... I wish I had more time to seek out the dark forces and join their hellish crusade."

As we reach the top of the house, we hit some of the aspirational parts of the house. Here we find making each others' life dreams come true. They encourage and support each others' hobbies and personal goals. When Morticia wants more time to herself after the birth of Pubert, Gomez listens to her vent, and is determined to find a suitable nanny so that she can spend more time on the dark arts.

“They're creepy and they're kooky, mysterious and spooky.”

The top of the house is where we have shared meaning. This is where we see something almost like a culture of two within the couple, consisting of everything from traditions to values. Family is clearly very important to the Addamses. They live with Uncle Fester and Grandma, and are very supportive of their kids. Strange as they are, they don't care what anyone else thinks, because this is what matters to them and what works for them. 

Thursday, September 17, 2020

Listen to Your Heart: a meditative practice

When discussing mindfulness, meditating is one of the first things clients and therapists alike bring up. Some of the most common advice is to focus on your breath. I often struggle with this, because breath is something you have control over. The moment I start thinking about my breath it changes. It's no longer natural, but performed. Many clients I've spoken to have reported the same, citing this as definitive proof that meditation doesn't work for them. However, meditation comes in many forms; breath is not the only point of focus your meditative practice can have.

A second style of meditation focuses on a safe or calm place or activity. This can be somewhere you've been (on vacation or at home), a favorite hobby (riding a bike, painting), or something completely imaginary. Of all the safe places friends and clients have brought up, a relatively common one is curled up with a partner, listening to their heartbeat. Many clinicians prefer clients choose a meditative place with nobody around, so that the scene still feels safe if stressors come up with that person. But it can be hard to deny the soothing nature of listening to a loved one's heartbeat, and harder still for those who are quarantined separately from their loved ones. While you may not be able to curl up with your partner, you can still listen to your heartbeat.

As I often do, I turned to good friends and trusted colleagues for their thoughts on this practice. Some liked having something steady to focus on. Others, however, found it easy to incorporate into deeper work they'd been doing. Those struggling with loneliness found it centering, and those doing inner child work found it soothing. It sounded like something worth trying. So one morning I sat down, set a timer, and closed my eyes. It took a moment or two to find my pulse, but once I did, I leaned into it. Soon, it was like my whole body was beating.

And it was kind of magical.

There is something vulnerable about noticing your own heartbeat, and this vulnerability can make the importance of tending to your own needs much clearer. I've since started using this practice as such, focusing on my heartbeat whenever I check in with myself. Noticing your heartbeat in a calm state can help you familiarize yourself with it more, and this can particularly be helpful for those who experience panic attacks and anxiety. If you know your resting heart rate well, you may get better at noticing when your heart rate starts to increase, which is often one of the earliest signs of panic. 

The feeling of focusing on your heartbeat is a prime example of what it means to just be with yourself. It makes it easier to tend to your needs, know yourself better, and help loneliness melt away. Your heartbeat is something you carry with you everywhere, making it a perfect tool for mindfulness and grounding. And with all the chaos going on in the world, we could all use a little serenity.

Tuesday, April 23, 2019

But what does all this paperwork mean?

By now, most of us are used to having to fill out a bunch of paperwork every time we see a new provider. Doctors, therapists, and other professionals have all sorts of forms and information we ask for before providing help, and for all sorts of different reasons. We've become so desensitized to it, that many comedians and shows have joked about not reading the terms of service, instruction manual, or even assembly guide for a service or product. Others get nervous when asked for so much information... what does it all even mean?

The first form that most therapists will hand you is the informed consent form. You might already be familiar with the idea of informed consent for medical procedures, research, or law. The basic idea of this is that the participant, patient, or client has been taught about whatever they will be undergoing, and agrees to it, with full knowledge of risks and benefits. This is fairly easy to understand when it comes to something like surgery; we know that the procedure may not work, or things may otherwise not go as planned. Similarly, therapy may not go as you expect. You may have skills to practice or work to do outside of therapy, and you may begin to notice thoughts and feelings you didn't notice before, whether due to increased awareness or to things changing. This can be quite scary. Fortunately, unlike with a surgery, you're not under anesthesia; you can talk with your therapist about how things are going for you, and adjust the plan accordingly.

The informed consent form will also tell you more about your therapist and their policies. This should include things like your therapist's licensure information, fees and insurance, scheduling and cancellation policies, and terminating treatment. Most therapists also have rules around contact outside of sessions, and this can vary a lot from person to person. Some therapists are available for emergency calls 24/7, while others can't promise to pick up, but will be able to call back. Therapists also have different policies about sending texts or emails, particularly if you want to talk about things typically discussed in session.

Therapist forms will also include a section on confidentiality. Typically, whatever is discussed in session stays confidential. There are, of course, some exceptions, which your therapist should explain to you in person. Therapists are mandated reporters, meaning that if they have reason to believe there is active suicidality, homicidality, or child/elder/dependent adult abuse, there is a requirement to intervene and report this to the proper authorities. There are also other specific cases that may override confidentiality. For example, if you are involved in a legal dispute and your mental health is relevant to the case, a judge could subpoena your therapist's records for use in trial. If you are seeing a therapist through insurance, than your insurance company will need access to information like your diagnosis. If you are seeing someone through a clinic or group, the confidentiality rules may extend to other clinicians within the same group, particularly if your therapist is in training. This information should be in the informed consent, though you can always ask your therapist if you're unsure.

Different therapists also have different confidentiality policies around child, couples, and family therapy. Many therapists utilize a no secrets policy with couples or families. This is particularly the case for couples, and meant to prevent one half of the couple from trying to get the therapist to ally with them by keeping something like an affair secret. When it comes to minors, the age and specific case matter a lot in determining how much the therapist communicates to the parents. In California, a minor over the age of 12 can consent to therapy without their parents present, if the therapist deems them mature enough. Thus, some therapists may choose to limit information they give to the parents when it comes to what is discussed in session, leaving it up to the minor themselves to decide. However, in some cases, parents are more involved in therapy. A therapist may give the parents a general sense of how therapy is going or what's being worked on without mentioning details into the kid's life, or may work concurrently with the parents to ensure the home environment is suited to the kid's needs, and help the parent better advocate for their child. For younger kids, the parents may sometimes be in the room during treatment. For older kids, the therapist may ask the kid themselves what they would prefer. It all depends on the therapist's view.

Among your starting paperwork, you may have received a packet talking about privacy practices. This is likely to be similar to something you've signed at a doctor's or dentist's office before. This is due to something called the Health Insurance Portability and Accountability Act (HIPAA), which is the standard for security for protected health information. This covers a lot of how therapists and doctors handle confidentiality and make sure client records are secure. Doctors and therapists will often discuss if certain services are "HIPAA-compliant", particularly online platforms used for messaging or video chatting; some therapists have access to secure means of remote contact that can be used to communicate between sessions, or even for remote sessions. HIPAA also requires us to inform our clients on how we keep their records secure by giving them a Notice of Privacy Practices and having them sign a page saying they received it.

There are a number of other kinds of consent forms that are also relatively common, depending on the case or therapist. If you have a doctor, psychiatrist, or previous therapist you'd like your therapist to talk with, you'll need to sign an authorization form. If you switch therapists or start seeing a therapist after having seen a psychiatrist for a while, this can help a lot. This can also help with issues that are partly medical and partly psychological, since therapists aren't trained in the medical side of client issues. For kid clients, it can also help to have their therapist in touch with their teacher or other school staff, particularly if academics or school behavior is affected by their symptoms. Some therapists will also have a separate Consent to Treat a Minor form for kid clients. There are also separate forms to consent to therapy over phone or video (often called Telemedicine) and forms to consent to audio or video recording (usually for training or treatment planning purposes).

The bulk of the information required from a client is in the intake form, also called the Biopsychosocial. Along with standard client details, it will ask about current symptoms, family history, substance use, medical history, work history, and much more. One of the most common areas of confusion here is the psychiatric history. This area asks if the client or family members have ever had prior outpatient or inpatient treatment. The difference between these two is that outpatient treatment is any kind of therapy where you remain at home and show up once or more per week, while inpatient is a program where you stay at the clinic, whether a residential treatment facility or a hospitalization program. Another area of confusion is the developmental history. A lot of people don't know or remember much about their childhood development. However, issues like early childhood illness, premature birth, or developmental delays can point at undiagnosed issues, cause problems that affect social and emotional growth (ie bullying), or otherwise correlate one's mental health.

Depending on your therapist or your case, you may also be handed additional forms to fill out. If you are looking for a particular diagnosis, or your therapist specializes in one, you may be given some paperwork meant to assess related symptoms or diagnose. Some therapists have policies around checking all clients for things like trauma or dissociative tendencies, as these symptoms aren't always mentioned or recognized initially, but their presence can change how treatment is handled.

Wednesday, January 16, 2019

Why Your New Year's Resolution Isn't Working

So, it's mid January. Just a few weeks ago, you were determined to start off the new year right, so you decided to make a resolution. Maybe it's one of the common ones, like exercising more, losing weight, or getting organized. Maybe it's more specific to your life, like visiting your parents more, actually using the vacation days you've saved up, or learning a language so you can travel or communicate with loved ones. You might have started out strong, like by starting a new diet, but maybe things are starting to get difficult, and you're noticing more slip-ups as time goes on. Or maybe you haven't really started on much yet, and although you got the gym membership, you haven't been once, thinking that you have the whole year to work on this. By February, actually achieving your goal may seem impossible. By March, you may have given up, or forgotten your goal entirely.

Over half of people who set resolutions in the new year fail. It can be so tempting to say that this year will be the year everything changes, but much harder to actually follow through on that. Change is a gradual process, and the more of your life you need to change to make the resolution happen, the harder it can be. Learning a language from a book is going to be difficult if you rarely read books. Further, if your resolution doesn't excite you, the motivation to change is small. No matter how excited your best friend or partner is about their workout regimen, you're not going to be motivated to try it if the pressure is entirely external. Maybe you'll go once or twice, but it's less likely to turn into a lifetime habit or hobby if it doesn't align with your priorities.

The resolutions I mentioned in the first paragraph reflect the most common ones. "Exercise more" is the most common new years resolution, with "lose weight" coming in second. You'll notice that many of the most common goals include the word more... "save more", "travel more", "read more", etc. But "more" is not specific enough! The vagueness of resolutions are part of why they are so often doomed to fail. A goal like "call mom more" doesn't tell you when or how often to do it. Setting goals should be almost as specific as coming up with plans.

The idea of setting a SMART goal is one that came first in the business and management world, but people quickly found it useful in their personal lives. The idea is that goals should be Specific, Measurable, Achievable, Relevant, and Time-bound. This is the difference between "exercise more" and "go to the gym twice a week" or between "learn Spanish" and "gain one level in Spanish on Duolingo each month".

To make your goal more specific, look at how you want it to be achieved. Are you losing weight by dieting, exercising, or both? What part of your life do you want to be more organized? Is there a reason for the goal, like fitting into a particular item of clothing, or getting a promotion? Saying you want to be healthy is a good theme, but saying you want to quit smoking is a more specific goal.

As you specify your goal, it becomes easier to make it measurable. If you've already decided you want to go to the gym, think about how often you want to go. Do you want to start strong, and go three times a week, or do you want to start once a week and work your way up? If the latter, make sure to plan out how you're working your way up. Starting at once a week and deciding you'll go every day "someday" isn't going to get you there. Saying you'll go once a week for two months, then twice a week for two months, and continuing on from there, is being specific about being measurable (and time-bound, but we're getting ahead of ourselves).

Making sure your goals are achievable can be difficult if you're the kind of person who will drop one goal in favor of something else, or if your goals are so big that you don't know where to start. Sometimes, making your goals more specific and measurable can help make them more achievable. But if you're not a morning person, waking up at 6 to go for a run every morning may not be the best way to get more exercise. Further, look at the skills and tools you currently have. If you want to eat healthier but don't know how to cook, buying a bunch of fresh veggies won't help much if you don't know what to do with them. However, starting with a frozen veggie mix for a stir fry might be closer to your skill level.

As you make your goal more achievable, make sure you're keeping it relevant to your overall goals. This lines up with making sure it's something you're motivated to do, as I said earlier. Setting a goal to call your mom every week is great, but if you're only doing it because you feel guilty for not talking to her enough, it's going to be harder to make that happen. Further, it can be easy to get sidetracked in working towards goals. If you decide you want to read more to learn about the world, make sure the books you're reading are relevant to the overall goal of learning about the world.

Lastly, giving your goals a time bound provides a sense of urgency. Many of us operate better with deadlines; it's what we're taught in school, and what keeps us going at work. Others are more interested in forming habits. Consider if you're looking to achieve something and then be finished with it, or if you want to work something into your routine. Do you just want to go on one vacation this year, or do you want to make travel a bigger part of your lifestyle? This can also depend on whether deadlines or routine work better for you. Some people are more likely to learn a new instrument if they practice every day. Others are more likely if they have a concrete end goal of "play my brother's favorite song at his birthday in June". If you have an end goal, go back and make sure it's achievable based on your starting point. If you've never played the piano, you may not be able to learn a concerto in three months, but you may be able to learn your favorite pop song by the end of the year.

Once you have a SMART goal, it can be broken down into smaller goals. What's the next step? It could be committing to a tool or method (i.e. learning yoga at a particular yoga studio), planning out your progress over the year, or even just doing more research. What can you do to make progress on your goal today? In the next week? This month? Keeping track of these smaller goals can help a lot, so your first step might just be deciding how to track your progress. This might involve using a journal or planner, an app with automated reminders, scheduling time to work on your goal, or regular check-ins with an accountability buddy.

As the year goes on, it can be easy to get discouraged. Skipping a smaller goal, missing a deadline, or slipping up once does not make you a complete failure. Focusing on your mistakes can be easy; part of why tracking progress is so helpful is that it can remind you of how far you've come. People who diet often talk about the concept of cheat days, and I think this can be applied to any goal. If you got home too tired to meditate before bed, that can be a cheat day. This concept helps in letting the mistake be an outlier, rather than feeling like making mistakes is part of the pattern. It can fight against the thought "I screwed up once, so why even try". If your goal was to finish reading a book every month but take a month and a week to finish one, you still finished the book. If you lose 15 pounds but your goal was 20, you still lost weight.

Remember also that life can be unpredictable and get in the way. You might not have the energy to cook a large meal if you're feeling sick, and that's okay. If your career gets more hectic, you may have less time to spend on hobbies. Sometimes, life gets so hectic that it's unrealistic to keep holding the same standards for yourself. It's okay to say you can only practice guitar on weekends, or that you can no longer afford to go to Europe next year. It's also okay to say rock climbing is no longer interesting to you, and you want to drop that goal entirely. Your goals should be serving you, not the other way around. It's all about getting what you want out of life, and part of that is knowing when to lean in and when to let go.

Wednesday, September 12, 2018

Sad, Mad, and Bad: What depression looks like in children

There are a limited number of mental health problems that are thought to affect kids. ADHD and Autism Spectrum Disorders are commonly diagnosed in childhood, while mood disorders are most common in teenagers and adults. However, this doesn't mean that children don't get depressed. Children experience depression differently from adults, and thus their symptoms can look very different. This can result in depression being underdiagnosed in kids, or not diagnosed until they are much older, despite early symptoms.

The most commonly known symptom of depression is depressed mood. In children, this can look more like irritability. They may have more outbursts, break down crying more often, or not get along as well with friends and family as they used to. The next most common symptom is anhedonia, which means less interest in pleasure. Kids may be less interested in seeing their friends or participating in favorite hobbies and activities. They might even come up with excuses or feign sickness so that they can stay home from a friend's birthday party or miss an outing. Adults often experience significant weight loss or gain, though this can be difficult to track in kids; instead, we need to look at where they are compared to their expected growth and weight gain. Kids are also more likely to have bodily symptoms, such as headaches and stomach aches, and may go to the nurse's office a lot with such concerns.

Of course, this is not to say that kids never experience adult depressive symptoms. Sleep problems are common with depression in adults and kids, as are feelings of guilt and trouble concentrating. However, kids are more likely to have trouble expressing these symptoms. They might not understand depression at all, or have the words to say what's going on for them. Even if they do, they might be afraid to express it. Depressed kids often withdraw from their families. If your kid avoids telling you about their day at school, they may be avoiding telling you about their difficult feelings, too.

Suicidality in depressed kids can be a tricky subject. Just because they're kids doesn't mean they don't get suicidal ideation, but not all talk of death indicates suicidality. This is especially true in elementary age kids, who may be just processing the idea of death or suicide, and who may be repeating things they've seen in the media or heard from friends. When kids talk about death, it's important to ask about the meaning of what they say and get a clear picture of what's going on for them before jumping to conclusions. The national suicide hotline (1-800-273-8255) has a youth division, and their website has many resources specific to many common causes of suicide in kids and teens, like bullying, gender/sexuality, abusive relationships, and more.

Many kids don't feel comfortable talking to the adults in their life. In some cases, it can be as simple as making sure they know you are a safe person to talk to. Talking about your feelings can help them feel more okay being open about theirs (even something as simple as "I'm frustrated that the waiter hasn't taken our order yet" or "I'm so tired from work"). Being more explicit about the okayness of difficult feelings might be necessary for some kids to safe talking about their difficult feelings. Just make sure you don't pressure your kids into talking to you. It's like one of those finger traps: pulling hard doesn't get them to open up as well as gentle nudges do.

If your kid won't talk to you, or you aren't sure you can help them on your own, therapy can be hugely beneficial. Not only can a therapist teach your kid about their emotions and how to deal with them, but they can also help you and your child open up to each other more. Cognitive Behavioral Therapy can teach a kid how their thoughts aren't always reliable (i.e. jumping to conclusions, minimizing strengths and maximizing problems, etc). Narrative Therapy can help kids explore who they are in relation to the world around them -- which can be important for kids nearing puberty. Gestalt Therapy can help kids process any bottled up feelings. Therapy can also help kids gain the communication skills necessary to talk through problems and difficult feelings with others. Many kids don't feel comfortable talking to the adults in their life, but are willing to talk to a therapist; often times the therapist is the only person in the kid's life who doesn't have expectations for them, and this makes them safe to talk to. A therapist isn't going to have a kid wash dishes or take a math test, and most kids understand that therapists are there to listen and help.

While childhood depression sometimes goes away, it can be hard to distinguish from lifelong depression in the moment. Untreated depression can make it hard for kids to learn, make friends, and thrive in their daily lives, and can thus affect their long term development. Symptoms of depression also often overlap with symptoms of other illnesses, mental and otherwise, so it is important to bring up any symptoms your child shows with their doctor. If handled effectively, childhood depression can often recede and leave no traces in adulthood.