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.

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. 

Friendzoned: How gender affects emotional support

Some of the first questions many therapists ask a client are those meant to assess their friendships and other close relationships. This is because having a supportive community is one of the biggest strengths in those facing mental health problems. Whether it's Generalized Anxiety Disorder or grief over a breakup, having people you can lean on for emotional support can help a lot.

Women are more likely to have such social supports than men. Part of this is due to traditional gender roles and expectations. Emotional vulnerability is considered feminine, and thus more acceptable for women than men. Of course, anger is an exception here, given that it is linked with violence, which is linked with masculinity. So men are more likely to come in with anger issues, while women are more likely to come in with anxiety and depression.

The second part of this phenomenon is the difference between male and female friendships. Because emotional vulnerability is acceptable in women, it becomes an important part of the way women connect with each other. You can see this in media directed at teen girls: they support each other at best and tear each other down at worst, but it's all based in their ability to be vulnerable with each other. The trope of the girl giving her friend a makeover isn't just about looks; it's about self-esteem. The image of a group of friends watching a sappy romance movie and eating ice cream after one of them was dumped isn't just about being there for the friend; it's about empathizing and validating her emotions.

So what happens when you remove the emotional vulnerability from a close friendship? You get something close to what male friendships look like: a connection based in mutual interests, activities, and practicality. While it's not uncommon for two women with very little in common to become friends, this is far more rare with men. A guy's best friend may be someone they go to the gym with, someone they sit next to at work, or someone who reads the same books they do. A girl's best friend is likely to be someone who knows her more deeply than anyone else.

Of course, this is not to say women don't have shallow friendships and men don't have deep ones. Even media sometimes portrays men with emotionally deep relationships. Usually, however, this is referred to as a "bromance" and is played for laughs. It's not often these kinds of relationships are shown between multiple men, much less being shown as the norm. When it does show up, it's far more likely to happen between brothers, work partners (ie co-detectives), or best friends. Further, this model is based on Western gender norms, and thus might not apply to everyone in the same way. Some cultures reinforce emotional support more or less, and in different ways. Western gender norms don't account for other gender identities either. Those who are nonbinary or from other cultures might find that this applies differently, or not at all. Still, this is a useful frame to apply to others, especially in noticing different expectations for a close friendship or romantic relationship.

Speaking of romantic relationships, this often ends up being where men get most of their emotional support from. This is especially true in a heterosexual relationship, where the woman sees emotional support as part of any close relationship, not necessarily something specific to romantic situations. In a sense, a man is more likely to put all his eggs in one basket. His girlfriend can get her emotional needs met elsewhere if need be, but to him, she is likely the only person he can talk to about his troubles. This is why, statistically, the end of a long-term relationship affects men more harshly than women. If your emotional support comes only from within a romantic relationship, being single means you don't get any support. Worse still, men who struggle in their dating life have little to no support around this struggle, which in turn makes it harder to date. It becomes a downward spiral.

What about friendships between men and women? Well, this is where things get complicated. The old adage "Men and women can't be friends" probably comes from these different perspectives in what a friendship consists of. This is also why a woman whose friendship with a man is high in shared interests and low in emotional intimacy might be seen as "one of the guys". Since men usually only get emotional intimacy from romantic relationships, they think of this kind of closeness as a hint that the woman is interested in them romantically. This link is so ingrained that some men may associate emotionally close male bonds with gay relationships -- note the root "romance" in the phrase "bromance", and how often media makes fun of close male friends by calling them gay).

This is where the idea of the Friend Zone comes into play; this phrase has come to exemplify the difference between male and female relationships. A guy who feels he has been put in the friend zone by a girl probably saw the potential for a romantic relationship due to their emotional connection -- something that is rarer for him than for her. However, the girl may feel like she was seeking a perfectly normal friendship with a guy, only to be surprised that he was seeking a romantic relationship with her! In both cases, expectations didn't match up, and this can lead to the end of the relationship. The guy doesn't understand why the girl would provide and ask for emotional support while wanting to just be friends, and the girl doesn't understand why the guy would assume she was romantically interested when all she was doing was being a good friend.

It is important to note that while traditional gender roles can sometimes feel like they doom us to a certain kind of life, the world is shifting rapidly. On any middle or high school campus you can often find a few guys who prefer to make friends with girls, and vice versa -- often because of the ways they prefer to have friendships. More and more, people are picking and choosing what parts of their expected role they want to hold on to, if any. A particularly introverted woman may not want to have friendships that are about anything but shared interests, and this is okay as long as she finds other ways to regulate and process her feelings. Someone else may have a best friend they rely on for emotional support, and many other friendships based on a shared hobby. Finding something that works for you matters more than doing what other people decide is the right way to be healthy.

I want to encourage you to examine how traditional gender roles affect the way you build your friendships. Even if you don't identify as a man or a woman, the existence of these roles and friends who do or don't ascribe to them can have an impact. Someone raised a woman may feel they are expected to do emotional work for all their friends because this is what it means to be a good friend. Their friend may have been raised to see male roles as being preferable, and thus not want to be emotionally close with or show weakness to any of her friends. There are many ways people can respond to expectations, and even the "emotional closeness vs interest focused" dichotomy is overly simplistic and contains many other dynamics within it. But having emotionally close relationships (even just one or two!) is a protective factor for those with lots of life stress. If you find yourself bottling up strong emotions, needing to talk to someone but not feeling like you can reach out, consider opening up to someone a little. It doesn't need to go deep fast -- you can start with how much you hate being stuck in traffic or that you're upset you have to work on a Friday night. And if they respond in a way that feels good? Then, this might be the start of a beautiful friendship.

When To Go To Bed Angry

Popular advice for struggling couples is to never go to bed angry. The thought is, to work on problems when they're fresh, rather than letting them simmer until they explode. While this is great advice for some couples (enough so that some make it a policy or rule within their relationship!) it can add to the tension for others. Why? It may lead to staying up trying to talk through issues when both people would rather be asleep. While it is important to talk about things that come up rather than putting them on the back burner, trying to talk things through when one or both people don't have the energy to do so can make the problem worse, not better.

This isn't just about arguments before bed, either. On the way to dinner with the in laws, while driving up a particularly difficult road, and before work are all times when an argument might feel particularly inopportune. Being able to save something like this for later is an important skill, both for an individual and especially for a couple.

If the thought of doing this makes you anxious or upset, notice that! There may be valid concerns underlying there, and maybe just waiting for a more opportune moment to talk things over isn't the best way of handling this. Does having to wait to bring something up make you feel like you're going to explode? Do you worry that the problem is going to be forgotten about and never discussed? Are you likely to forget all the emotions around the problem in the morning, and undersell yourself? These thoughts and feelings are important to take note of, so don't just push them aside. This is all information that you can use.

Something that might help quell these fears of putting off a discussion is to record your feelings while they're fresh. Any time you put off a discussion for a time when emotions aren't as high, it can feel like you're likely to forget something or sell yourself short. Depending on how you best process information, you can try writing something down in a journal, typing something up in Word, or recording yourself talking into your phone. You can format this like a list of talking points, pretend it's a letter or voicemail to the other person, or just ramble until you have nothing left to say. Later, when it's time to discuss the problem, you can choose to show the other person your recording or writing directly, or read/listen to it yourself and tell them whatever you feel still sticks. It's entirely possible that you'll realize that you completely disagree with your past self, and that's perfectly okay! This is part of the reason why it can be good to put off discussions like this in the first place -- anger and fear can cloud discussing what's really going on.

Getting some distance from an argument can also help in making sure you don't play your normal role. If you're likely to get angry and your partner tends to withdraw in fear, keeping a calm head can help your partner stay engaged during what might otherwise be a rough conversation. Looking back over your thoughts, you may notice somethings that come up when emotions are high, such as blaming, hiding, or defensiveness. Notice what tactics you're prone to using. And next time you and your partner start to argue, see if you can change the normal course of it -- even if that just means talking about it later.

Communication and the Desired Response

A friend once told me a story of how an interaction with her mother changed her perspective on communication. She said that she had been going through a break up at the time, and was venting to her mother, when her mother responded with "Do you want my advice, or my sympathy?"

Often times, when we have something important to talk about, we consider how we expect the other person to respond, and talk to people who will respond the kind of way we want. We may choose to speak to someone who we know can keep a secret, or who gives good advice, or who will say nothing at all, only listen. Sometimes we may turn to someone who won't want to talk about it at all, and will instead distract us from our problems. This can be great if you have a number of close friends who reliably respond in different ways, and you are able to predict this and make use of it. However, not everyone is in this situation, and so instead, we end up with interactions where people are not getting their desired responses.

Take an interaction between example-humans Alice and Bob. Alice's goal in the conversation may be to be heard, whereas Bob may want to feel validated for what he says. If Alice is talking, Bob may point out something or make a clever remark. Instead of validating Bob, Alice feels like she hasn't been heard, and is quiet in response. Now Bob has not been validated either, and they are both sad.

Sometimes, a person's desired response can be inferred. This is like how generally, if someone tells a joke, their desired response is for you to laugh, or at least acknowledge that the joke was funny. However, this isn't always easy to tell. Some of us may know the best thing for our best friend in a time of stress, but we don't always know what's right for someone else, even if we are close. Often times we will assume that what works for us will work for them, but then there is a risk of emotional damage. Trying to talk about a situation that someone wants to avoid thinking about may exacerbate the problem or cause tension between two people. Usually, it is better to ask a person what they need -- like how my friend's mother asked her.

Going more deeply, some people may tend to have common desired responses, in general interactions. Think of the person constantly telling bad jokes, excited to hear people groan and laugh, or someone who loves giving advice and recommendations. The first of these two may love the validation they get from humor, whereas the second may want to feel helpful, and be appreciated for it. This goes far deeper than a single situational interaction; these people want these kinds of responses in everyday conversations. This may even tie to how we want others to see us (clever or kind) or how we most enjoy interacting with others (playing with ideas or working with people, receiving attention or giving it). A person's desired response may not always be the response that feels right, or the response that we want to give -- and that's perfectly okay. But it does give us insight into what drives them, what is important to them, and who they are as a person.