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.

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.

Humanistic

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.

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. 

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.

Time vs Task: Bounds of attention

I once worked in a special needs class that consisted mostly of kids with Downs Syndrome and Autism Spectrum disorder. There were many patterns I noticed that ran through both groups, but at the end of the free period when we had to draw the students' attention back to classwork, one difference became clear: their attention spans.

Kids on the Autism Spectrum would drop what they were doing as soon as they were told that it was time for lecture. To these kids, making sure everything scheduled happened on time was important; if something came up and they had to skip math, they would be distressed -- even if they didn't really like math. In contrast, kids with Downs Syndrome wanted to finish what they were doing. If they were in the middle of a puzzle, they had to finish it. If they were watching a Youtube video, they couldn't hit pause until it was over. We'd have to keep track of their activities and anticipate when a good time to pull them away. If a kid was listening to music, we'd approach them five minutes before the end of the period and allow them one more song.

This is not meant to draw boundaries between diagnoses (not every person with one of these conditions will act like the kids in my class did), but it does illustrate two very different approaches to attention: time-bound and task-bound. Someone who prefers to stick to a schedule is more likely to have time-bound attention, finishing a task when it is time for the next task, even if the previous task isn't completely finished. Others may be more task-bound, preferring to finish one task before moving on to the next.

To apply this to yourself, imagine being a child reading your favorite book before bed. You are told that it is time to go to sleep, but you are in the middle of a chapter. How reluctant are you to put the book down? Regardless of how good the book is, are you willing to go to bed before the chapter is done?

Variable answers are expected here. A gripping mystery novel is going to treat your attention differently from a comic book, in the same way that activities you enjoy feel different from those you don't. A person's willingness to move on to the next task may depend on many things, including time spent or remaining in the task, time until you can return to the task, enjoyment, and rarity of the task. You may be more reluctant to leave a party if you are talking to a friend you haven't seen in months, or if you just started playing a particular game with them, even if your attention is typically more time-bound.

Stress can come up interpersonally when one person is time-bound and the other is task-bound. If two people are putting together a puzzle and it's time for dinner, one might want to pause to eat, while the other might want to finish the puzzle first. Similarly, if a person who is time-bound is waiting on someone task-bound, they may end up waiting longer than they expected, depending on what the task-bound person is doing. It is important not to act like one of these ways of viewing attention is "correct"; they both have strengths and flaws and places where they are more or less appropriate. Just as it may hurt to stop an important conversation before wrapping up because it's "time for lunch", it would be inappropriate to drag an appointment over time if one or both parties has another appointment right after.

Next time you find yourself in a battle between the task at hand and the next task, notice where your attention is drawn and why. Notice how fluid this is -- your willingness to be time-bound when you want to be task-bound, or vice versa. Your answers may differ each time you try this, or they may show consistent patterns in your behavior. And once you've noticed these patterns, you can better examine how that changes the shape of your life.

The two types of Self

When you think of the Self, do you imagine it as something growing and changing, or consistent over a person's life? The definition of the Self is arguably one of the biggest differences between classical and postmodern psychology. Classical theories have their basis in the idea of a True Self, a fundamental unchanging part of a person that stays with them since birth. They may talk of upbringing, life circumstances, and social influence as things that change behavior, but they never change who you are underneath all of that. An artist may always be an artist, even in a world where they had no choice but to sell bread and raise children.

Postmodern theories of psychology look at the ways our behavior changes overtime, and instead see the Self as that which changes. Just as a person can change what they like, they can change who they are. A rambunctious teenager can change and become a stoic adult, and this isn't because they became any more or less in touch with a True Self, but because that Self changed, whether due to social pressure or just maturity.

These different perspectives change the ways clinicians approach their clients. A therapist who believes in the True Self may push a client to become more in touch with lost parts of themselves, while a more postmodern therapist might push a client to grow and change, exploring new hobbies and not remain attached to certain parts of their identity. I want to propose a third idea, which is that this theoretical rift is caused by two different definitions in the word Self.

In a sense, this debate is no different from nature versus nurture. While popular science shifts focus between the two, the truth is somewhere in the middle. Some of who we are is in our genes (brown eyes, wavy hair, a bit of a sweet tooth). The rest (taste in music, friends, hobbies) is influenced by how we are raised. So it can't be radical to suggest that between the True Self and the Changing Self, both as well as neither are true.

The two types of self I want to talk about are those I call the Momentary Self and the Lifetime Self. While there are parts of a person that never change (LS), it is impossible to ignore the ways in which parenting, culture, trauma, and major life events can change a person (MS). Difficulty comes with distinguishing which parts of a person are part of which Self.

Perhaps the most salient example of this in recent history is the debate on where sexuality comes from. While there is a major movement of people who believe that LGBT identities are inherent, there is a significant population that doesn't feel this to be the case. For example, people who have experienced traumas in early childhood may feel that those traumas made them gay or lesbian. The fact that they weren't "born this way" doesn't make their sexuality any less valid. Further, some feel their sexuality is fluid; not only has it changed, but it is likely to change again in the future. While the first population may have sexuality as part of their Lifetime Self, these people may see it as part of their Momentary Self. For a less controversial example, you can note the difference between someone who has been highly social since birth and someone who has taught themselves to be more social. Both may see extroversion as a trait they have, though they came about it in different ways.

It can require a lot of work and introspection to know which parts of yourself are Lifetime and which parts are Momentary. The assumption of identity being one or the other is dated; it may take more work, but sorting through the parts of Self can do a lot to settle things like self esteem and compassion. Trying to change something that's part of your Lifetime Self can be frustrating. Insisting that part of your Momentary Self is stuck like that forever can be stifling. Letting these parts speak for themselves can be freeing.

The Universe Inside Your Head

Let's say you are reading a book about people with magical abilities. As a young child, their abilities manifest spontaneously (accidentally breaking something with their mind, flying instead of falling, etc). Then, they are taken away off somewhere to learn to hone their skills. There may be rules to what magic is and is not possible, how magic is done, and what different students can learn. In this book, the main character has the ability to manipulate electricity. They can use this to control anything that operates with electricity remotely, like by turning lights on and off, or they can just shock people. If it is established in the book that no person has more than one ability, you may be surprised if, later on, the main character starts to manipulate water or read minds. This changes the rules of the story.

In the above paragraph, I painted a picture of a universe, giving you rules about how it worked. If I asked you to write a story within the universe, many of you might take care to make sure the story abides by the rules I have provided. This ability to create a universe in your mind is a skill not everyone has, but it is useful beyond just reading stories and writing fanfiction. This same skill can be used to understand people, and even ourselves, better.

To tie this to another example, let's say you are speaking with someone who you just met. This person is an elementary school teacher. Right away, you know quite a few things about this person (they work with kids, get summers off, probably teach during the day and maybe grade papers and plan lessons after school). In the same way that you did with the book, you can use this information to give more detail to this person's universe. Now maybe the person tells you that they also run a summer camp. If you previously assumed that being a teacher meant they had summers off, now you can update the information you have on this person to include that they have a second job they work over the summer. You now have a slightly more detailed picture of what their universe is like.

Though the example above is a relatively simple one, there are lots of ways to gain information that you can use to add detail to someone's universe. Often times we don't even realize we are doing it; assumptions made based on a person's appearance or social media profile aren't always conscious. There are even small things people say and do that we miss, but could otherwise be useful information in understanding the person better. If someone tells you a movie they saw was "too scary", it may not be a fact about the movie, but about their dislike for horror movies, or fears surrounding the topic of the movie.

The perspective we use to analyze other universes is also important, because it determines what we notice and what we don't. When reading books, we may not think much of things that are normal for us, like a 6-year-old going to school for the first time, but notice things that are not true in our universe, like super powers. The more ways a fictional universe is different from our own, the harder it is to keep track of. Imagine how much easier it might be to follow a book about super heroes, rather than a book about aliens and monsters with magic and futuristic weapons! This is part of why we enjoy spending time with and talking with people who think similarly to us. If a friend's universe is similar to yours, it takes less effort to understand who they are and why they do what they do.

If you meet someone whose universe is too different from yours, you may find them hard to relate to. Part of this is because, by default, we use our own universe to look at other universes. A young child who doesn't know the meaning of divorce might have a hard time understanding the experiences of their friend, who spends half their time with Dad and half their time with Mom, but never together. The child may get frustrated if that friend leaves a book they borrowed at Dad's house, then didn't have it when they spent time together after school at Mom's. It can be so easy to judge other people without thinking about whether what happened makes sense in their universe if it doesn't make sense in yours. The child may assume that the friend didn't want to give the book back or was trying to be mean, rather than realize how easy it is to forget something at one house when you have two. Even adults do this all the time, assuming malice or stupidity when we can't understand another's actions. Taking care to understand another person's universe can help prevent this from happening, sometimes drawing attention to parts of your own universe that you take for granted in the process.

As a therapist, this skill is particularly useful. Creating a vivid picture of a client's universe is essential to helping them understand themselves and their relationships with others. If a client identifies with a particular fictional character, for example, they may be better understood if you take care to learn about the character and the story they're in (either by asking the client, or through direct exposure to the story). A child who enjoys imaginative play can be understood through the assumptions they make in their play (like the assumptions about who does what in a game of house). Even clients with compulsions, fears, and delusions can be better understood through those symptoms. Different therapists will prefer different theories and interventions, which means they will each have different ways of gathering information about their clients, but in the end, the therapist who interprets dreams and the therapist who gives their client hypothetical scenarios are both using the information they gather to create a richer, more detailed picture of what that client's universe is like.

The 5 Stages of Grief, and Why They May Not Be Accurate

In Western culture, we often talk about grief coming in phases. When we first hear about death of a loved one, we may not believe it. Then, once we come to terms with it, we may need to mourn for a very long time before we are able to move on. Many cultures around the world have ceremonies and traditions that deal with mourning, but in the US, people most often talk about the 5 Stages of Grief. This model, also known as the Kubler-Ross Model, goes as follows:

1. Denial (this can't be happening)
2. Anger (why me)
3. Bargaining (maybe if...)
4. Depression 
5. Acceptance

This model, though it does focus on grief, was developed specifically in relation to those who are dying. Rather than being developed about someone grieving a dead friend or family member, it was meant to teach loved ones of a dying person what they go through emotionally upon finding out that they are dying. So, for example, the bargaining phase is not meant to show that a person may think there is a way to get their dead friend back. Instead, it shows that, at a certain point, a dying person may be convinced that there is a way to cure them of whatever is killing them, or hope that their illness may mysteriously disappear.

So what does the process of grief actually look like?

In the 80s, John Schneider developed what he calls the Transformational Stages of Grief. This model looks not only at emotional responses, but cognitive, behavioral, spiritual, and physical responses as well, and thus is designed to nurture growth. Rather than just covering loss of a loved one, it also covers other losses like break ups and divorce, as well as more internal losses like a change in beliefs or a loss of faith. Schneider's model is:

1. Initial awareness of loss (shock, confusion, disbelief)
2. Attempts at limiting awareness by holding on (bargaining, guilt, ruminating, and trying to use coping behaviors that have worked in the past, all in attempt to put off instability. often associated with insomnia, muscle tension, and yearning.)
3. Attempts at limiting awareness by letting go (depression, anxiety, shame, pessimism, forgetting, and hedonism, sometimes involves giving up on formerly held ideals and beliefs)
4. Awareness of the extent of the loss (mourning, deprivation, grief, defenselessness, flooded thoughts, noticing what you are now missing)
5. Gaining perspective on the loss (healing, peace, acceptance, noticing growth and change, awareness of the extent of your and others' responsibility, realizing any positives)
6. Resolving the loss (self-forgiveness, finishing unfinished business, accepting responsibility, saying goodbye)
7. Reformulating the loss in a context of growth (discovering potential, problems as challenges, regaining curiosity, think of a divorced person who has decided to start dating again)
8. Transforming loss into new levels of attachment (awareness of interrelationships, wholeness, empathy, end of searching, reflection)

As a counterpoint to traditional models, there is also what's called The Dutro Model, which doesn't focus on stages at all. This model claims that traditional "stages of grief" models are not supported, and placing time limits on grief is inappropriate. It also holds that pathologizing the suppression of sadness as a response to grief is also incorrect. Instead, the model sees grief as being complex, multidimensional, and individualized, based on a number of variables that are different for each person's individual experience. 

Often times, a grieving person can expect a flood of support when people first hear about the loss, though the support may wind down when the news is no longer as new. It is important to keep in mind that grief can go on for a long time. Sometimes, particularly when grief involves trauma, people can experience post-traumatic stress along with their grief. Think of the couple going through a particularly contentious divorce, or someone who witnessed a friend being killed. This can result in a complicated grief reaction, which can take much longer to process than grief on its own. 

Ultimately, each person's experience of grief is going to be different, depending on the type of grief they are going through and the circumstances around the loss. Stage models are useful for those in the middle of the grieving process, as well as friends and loved ones of the grieving person. The grieving person may find comfort in knowing what may happen next and understanding that this too shall pass, while their friends and family may feel that knowing what's going on and what to expect can better help them be supportive. Complicated emotions around grief can be sudden and painful, or they can sneak up on you when you don't expect it. Understanding what you are going through and knowing that you are not alone in your experiences can often be one of the most helpful things in getting through that dark tunnel and out the other side.

How social media can affect your sense of self

When we check social media like Facebook and Instagram too often, we can be inundated with the good parts of peoples' lives. Facebook in particular has an algorithm that results in a news feed that prioritizes things to celebrate, like an engagement, a baby, or a new job. Then, when we scroll down an individual person's page, we see their highlights: how their diet has been, or fun things they do with their friends. What we don't often see, though, is the days they are home alone, in their pajamas, watching Netflix all day. This is especially the case with any friends who we only see online, whether due to distance or time; we only see the parts of their lives that they consider to be worth documenting. And when this happens, we often end up comparing the best parts of their lives to the worst parts of our own.

Social media is developed in such a way to be about building ourselves up. As we share our accomplishments and daily lives with the world, we get responses (likes, comments, reactions). Something as simple as discovering a new restaurant and having friends comment on how delicious the food looks can be a boost of self esteem, even if the same information shared in person wouldn't quite have that strong of a result. Along with insight into our lives, we share insight into our minds: interesting articles, funny pictures, and our thoughts about the world. We may intend to use these to share things we think are important to share (whether for humor or insight or both), but the result is also that it paints a picture of who we are. One particular friend may share lots of politically-charged articles, and that makes your picture of who they are very different from someone else, who shares recipes and DIYs, even if the rest of their content is exactly the same.

Having such insight into who someone is through social media creates an interesting effect; you may know a lot about the person, but that doesn't necessarily mean you are close. For example, you may have read your coworker's posts about all the things their kid says, and even watched videos of their home life, but never quite feel comfortable with them enough to get lunch with them. You may have a friend who you have only met in person once, and have shared incredibly personal things with on chat, but then when you meet them a second time after all these conversations, it feels like there's nothing to talk about. Of course, this isn't true for everybody. For some, it would be easy to find things to talk about with that friend, and no trouble at all to ask that coworker to get lunch together. But usually, the way friendships are formed in person is very different from how they are formed online. The coworker, for example, may know very little about you (despite following and friending each other!), despite how much you know about them.

Part of what's missing here is the humanness that comes with everyday interaction. When in school, you may see your friends everyday, and freely rant about teachers, homework, parents, and other kids at school. You share not only successes, but failures, and places where you need to grow. Online, we portray ourselves as robots, gods, and forces without boundaries. A profile can often read more like a marketing campaign than a human being. It is as if we are trying to disassociate from our own humanness. Recognizing our humanity, and the humanity of others, is important in making the world better, and for so many reasons. Going back to mental health and identity, though, it normalizes suffering. It creates a world where it is okay to lose sometimes, and where someone can feel sad without that sadness becoming a part of who they are. There are ways to do this in online communities. I know people who have created secret Facebook groups for close friends to share painful day-to-day moments, so they can receive support, or who have joined forums so they can hear from people with similar life experiences. But it takes initiative, as well as courage, just as it does in real life.