It’s not easy to find a good therapist. Therapy can be incredibly cost-prohibitive, for one thing, depending on insurance coverage. Then, there are scheduling constraints (it’s hard to find a therapist with open hours if you work a traditional 9-to-5), location constraints, general time constraints, and trying to suss out whether or not the person you’re spilling all your shit to is the right one to help you unpack and repack it.
There are also hundreds of different types of therapy, which is daunting when you’re not sure what kind will work best for you, in addition to a slew of different categories of mental health professional, all of which come with different credentials and training. It’s a lot to navigate, especially when you’re a first-time client. Here are some tips for selecting the right kind of help.
What kind of therapy do I need?
There are many, many different types of therapy, and mental health professionals don’t necessarily use a one-type-fits-all approach. If you’re suffering from something like generalized anxiety disorder or depression, for instance, your therapist might use a combination of treatments in your sessions. But let’s take a look at some of the most common options:
CBT is a common treatment that focuses on looking at certain behavioral patterns and coming up with a game plan of sorts to break them. “It’s trying to help you change your behavior through thinking differently about your situation,” Ryan Howes, PhD., a clinical psychologist in Pasadena, California, says. “So, for instance, if you get anxious about confronting your boss at work, or anxiety stops you from making any movement, CBT can help you reframe that. Instead of thinking of all the horrible things that could happen, it’ll help you imagine positive outcomes.”
CBT therapy is usually short-term—your therapist helps you determine a specific goal, and will then work with you to help regulate your emotions and develop new personal coping strategies. It can be especially good for treating anxiety and depression.
Psychodynamic therapies like psychoanalysis and Jungian therapy involve digging into your past to look at the root of whatever problems you’re trying to treat. So, for instance, if you’re anxious about confronting a boss, a psychodynamic approach will try to determine when this particular anxiety first took place, and how early traumas and relationships contributed to your current predicament. “The idea is that being able to uncover early thoughts will free you up to be able to act differently,” Howes says.
Psychoanalysis can take a long time (like, years) and many therapists will use it in tandem with a CBT approach, which is something worth bringing up in a consultation.
Specialized therapies for specific disorders:
Both CBT and psychodynamic therapies (or a combination of the two) can be effective for more general mental health disorders, but f you’re struggling with a particular disorder, like an eating disorder or post-traumatic stress, it may be more beneficial to see a mental health professional who specializes in treatments targeting those issues. For instance, if you’ve suffered from trauma, there’s Eye Movement Desensitization and Reprocessing (EMDR) therapy; if you’re mourning a tragic death, there’s grief therapy.
The thing about therapy, though, is that you might think that CBT will help you the best, or that you want deep psychoanalysis, or that only one specific kind of treatment will help you. The reality is that therapists will often use multiple approaches when treating a patient, and though it’s helpful to find a therapist who specializes in a particular disorder, when you start seeing one, you may discover it’s not just anxiety or grief that’s causing you problems.
“Nobody walks in the door with one problem,” Faith Tanney, a psychologist with a private practice in Washington, D.C., says. “You have to be able to switch around with different modalities.”
More importantly, if you like your therapist and feel comfortable opening up to them, the type of treatment they specialize in might not make a difference. “If you think your therapist is healing you, stay with them,” Tanney says. “If you don’t think your therapist is helping you, I don’t care what kind of therapy they’re doing.”
What kind of mental health professional should I see?
There are a few different kinds of people licensed and qualified to provide therapy. Psychologists have PhDs and PsyDs, and are trained in both psychotherapy and assessment testing. Licensed clinical social workers are also trained in psychotherapy and perform functionally similar mental health services to psychologists, but don’t have doctorates. A licensed mental health counselor is also trained in psychotherapy and will treat patients much in the same way as a social worker. Psychiatrists primarily focus on chemical imbalances. They have medical doctorates, and prescribe medication (in some states psychologists can also prescribe medication).
A psychiatrist is the one to see if you’re in the market for mood-correcting meds, but if you’re looking for talk therapy, you’re better off seeing a psychologist, social worker, or counselor. Psychologists tend to see people with serious mental illness, while social workers and counselors can help patients suffering from more common forms of psychological distress. In the long run, though, as long as you’re seeing someone with a valid state-issued license (states have online license lookups for psychologists, counselors, and clinical social works), if you like your therapist, their specific credentials don’t really make a difference.
What research should I do before having a consultation?
There are a lot of different factors that go into finding a therapist. Therapy is expensive, so if your health insurance will cover it, it’s a good idea to search for one through your provider, though some therapists will offer counseling on a sliding scale. Location is also a big factor—if you think it’ll be difficult for you to get to your therapist, you’ll probably be less likely to make your appointments, especially when you’re still in the “feeling it out” stage.
If you’re looking to treat a certain problem, you do want to know your therapist has some experience in that realm. If you struggle with anxiety, your therapist should know how to treat anxiety. If you have bulimia, your therapist should have experience with patients with eating disorders. Websites like therapy.organd Psychology Today will tell you a little about your prospective therapist’s areas of expertise, so you can get an idea of what you’re working with.
Then, you have to take into account your personal preferences. “Some people feel like they want someone who fits in a certain age bracket. Some want someone a little older and wiser, some people feel more comfortable talking to someone around the same age,” Howes says. “Gender is a big part of it, too. I tell people to try to make a list of three therapists that on paper seem to fit their criteria, that are the right age and specialize in that area, and go on a test drive with these therapists.”
What questions should I ask in my first session?
When you’ve selected your three therapists, you should set up a consultation, either by phone or in person. Sometimes therapists won’t charge for consultations, and sometimes they will, so it’s a good idea to suss that out beforehand.
Once you’re at the consultation, though, the most important thing is to get a feel for your therapist. “This is like a first date,” Tanney says. She recommends skipping over the “where did you go to school” part of the standard dating questionnaire—“They’re already licensed, so you can sue them,” she jokes—and getting right into your particular goals and how they might go about helping you achieve them.
“You got my name from someone. You’ve read up on me, and see that I have the skills, I have the techniques, I have the training, I have the experience. Now we’ll see if that works for you,” Tanney says. “We set goals for therapy, I’ll tell you what I think we’re going to work on first, and you say whether or not they make sense to you.”
It’s also a good idea to ask your therapist for their specific policies—some require advance notice if you’re canceling a session, for instance, or will only allow you to take a couple weeks off without being charged. Some will ask that you give them a few weeks’ heads up before you decide to end therapy. “If you feel the time has come to leave, I would ask that you let me know, so we have a couple weeks to discuss that,” Tanney, who has her patients sign a contract, says.
Ultimately, go with your gut
The real key to finding a therapist is exactly like trying to find a romantic partner—there has to be a “click.” After a couple of sessions, if you don’t feel like your therapist is someone you can open up to, then they are not the therapist for you.
“It’s about trusting your gut,” Howes says. “The therapist can be the most highly trained person in the world with years of experience and mountains of books, but if you can’t open up to them, the therapist is worthless. Or they can be a brand new trainee, but if you feel safe and comfortable talking to them, the therapy will be more beneficial.”
So if you’ve test-driven a few therapists, pick the one you felt the most comfortable talking with. And if, after a few sessions, or a few months, or a few years, you decide you’ve lost that connection, it’s okay to leave. “You have the power. This person is in your employ,” Tanney says. Don’t ghost, and do bring up your specific concerns about your therapist to them, since it’s always a good idea to give someone an explanation as to why you think things aren’t working. But you’re the boss. After all, as Tanney says, “This is not your friend, this is your worker bee.”
Therapy is often touted as a ‘safe place’, when, in fact, it is anything but that. It is a place where we surface our demons, dig deep into our neuroses, explore our habit patterns and challenge belief systems that often do more harm than good. Therapy is a place where we learn to be uncomfortable with ourselves, so we can, ultimately, become more comfortable with who we are and our place in the world.
We Don’t ‘Get Better’
The spiritual teacher Ram Dass is often quoted as saying that, after 40 years of psychotherapy and meditation (for those unfamiliar, Richard Alpert (Ram Dass) is himself a clinical psychologist and former Harvard professor), he is no less neurotic than he’s ever been—now, he simply invites his neuroses over for tea. This statement is a bellwether for those of us doing ‘the work’, in that it intones exactly what happens through the process of self-examination. We don’t ‘get better’. We diminish the charge of our struggle, reframe it and use what we’ve learned to make less destructive—and, in some cases, more productive—choices.
Before that happens, however, we need to sit in our sh*t—surfacing our demons, digging in the dirt and deconstructing those repeated patterns of thought and behavior that seemingly and inexhaustibly dog our relationships, careers, family interactions and, often, every other aspect of our lives from finances to self-care. There is nothing to predict what prompts us to make this choice. It might be a bad breakup, the loss of a job, griefaround a loved one or the simple existential realization that something just isn’t quite right with our world. No matter what the motivation, the call to self-examination is a powerful one and, more often than not, heeding that call can, at least for a time, make matters worse.
Shedding Light in the Dark
We all have skeletons. Life sometimes opens the door on that closet, amplifying the power those pesky little fellows have over us. For instance, a reflexive tendency to people please might, in the context of new relationships, turn the corner into unhealthy co-dependence, or unmet needs may, over time, build resentments that express themselves, if not as misplaced temper tantrums, at least in uncharacteristic acting out.
This leaves us with a choice—we can stay stuck in our struggle, or we can turn inward and explore our own inner darkness—our shadow self. Should we choose the latter, we will find that, just like a child who learns without a nightlight there’s nothing to be afraid of in the dark, entering the tomb of our inner landscape can, ultimately, only shed light on our darkness. In making the choice to turn inward and enter the tomb, we also choose to first recognize, and then embrace, our vulnerabilities, imperfections and, sometimes, flat out forays into Crazy Town. That’s when things get interesting and, more often than not, more than a bit messy. It’s also where ‘the work’ happens.
Becoming a Witness
One of the most important tools in this process is developing something called ‘witness consciousness’. This is a state of natural presence—operative word here being presence—where we objectively observe our thoughts and actions. It is not a state of disaffectation or emotional absence—quite the opposite. Witness consciousness is a relaxing back into an awareness of what is happening for us—in our bodies, with our thoughts and with our emotions. It is the lever that prods us into our discomfort and prompts us to see what it is we’re actually up to, and a window into our rapprochement—the way we are in the world. That window overlooks a landscape that leads to myriad paths tracking back to everything from our attachment issues to the shaping of our worldview. With the revelation of that perspective, we quickly discover we aren’t in Kansas anymore.
Source: WikiMedia Commons
This revelation is very much a reflection of what, in literature, folklore and narratology (the study of narrative and narrative structure) has come to be called ‘The Hero’s Journey’. It is the bridge between our challenges and transformation, and the light we shed in the tomb of our inner landscape. In that abyss, we have the opportunity to discover our true nature; what in post-modern spiritual practice has come to be called our ‘authentic self’, and, in Buddhist psychology, our ‘awakened heart’.
Truth be told, we’re going to fight it. Whether we’re talking about a story arc or real life, the revelation of the authentic self means change, and change is hard, to say the least. We’re going to push back—and hard. Shedding the mortal coil of our daily burdens, and coming to terms with our true nature, is probably one of the most significant, dangerous and enlightening choices we can make, but it does not come easily. Shedding that mortal coil is, in some ways, like a shedding, not of a skin, but the armor of what we feel is our humanity, which, in truth, is our isolating sensibility of separateness.
In the space between our challenges and our transformation, we encounter, not only the ego-self—the separate self we believe ourselves to be—and the authentic or awakened self, but the shadow-self. Engaging the shadow-self, and the energies it brings to our lives, we are presented with an opportunity for an integration of these disparate elements of self. The tomb becomes a womb—a sacred space where we experience the death of the former and the birth of new, entering into the light of our transformed, whole and integrated self.
The Hero’s Journey is not for the faint of heart, and many turn back on their path. For those willing to stay the course, braving the perils of our own inner the landscape and embracing the change we so fear, there dawns not only a new day, but a new way of being in the world.
Like all emotions, anxiety is healthy, and we’re all prone to feeling it sometimes. Anxiety can become a debilitating problem, though, when the stress you feel is no longer in proportion to the situation. An upcoming test, jobinterview, or first date may make you feel anxious, and that’s healthy. But, if you feel symptoms of anxiety absent any apparent reason, or everyday things make you anxious—leaving your home, for example—it may be time to see a mental health professional. To know if your anxiety is unmanageable, you have to know the symptoms.
1. Physical Symptoms
The physical symptoms of anxiety may include an upset stomach, excessive sweating, headache, rapid heartbeat, and trouble breathing. If you get a stomach ache every time someone invites you to a social function; if you sweat through your shirt whenever you leave the house, even in the middle of winter; or if you feel like your heart is beating so fast it might burst when talking to a stranger on the phone, you may be unhealthily anxious. If your body regularly reacts to everyday stressors the way a caveman would if a lion chased him, your anxiety is no longer healthy.
Memory issues, trouble concentrating, and insomnia are also symptoms of an anxiety problem. If you can’t fall asleep or wake up repeatedly during the night because you can’t stop thinking about things that stress you out, anxiousness is ruling over you. The same goes for if you can’t focus on work, or sit through a movie, or read a book, or if you seem to be continually forgetting things that happened even recently. When you’re severely anxious about something, even if the thing is “irrational,” it can be hard to function normally.
Whether it’s procrastinating about doing the thing that triggers your anxiety—like putting off an errand or not reading an important email until you’re “ready to deal with it”—or avoiding doing just about everything, excessive procrastination and avoidance are both signs of an anxiety issue. We all put off starting unpleasant or difficult tasks sometimes, but when you spend more time avoiding than doing, it may be time to seek outside help.
4. Overthinking and Constant Worrying
If worrying keeps you from functioning or you’re overthinking so much that you can’t focus on important work or sleep at night, you may have an anxiety problem. Your mind races, you lose track of your surroundings, and you’re so caught up in a storm of stressful thoughts that you miss your freeway exit. Anxiety tips over from healthy to unhealthy when it disrupts your life. If a recent health diagnosis has you worried, that’s totally normal. If you’re afraid that you’re dying every time you sneeze, that’s not.
5. Feeling Agitated and Restless
If you feel on edge, you can’t stop moving, and you’re quick to anger, you may be anxious. I’ve written before about how anger can disguise itself as anxiety, but did you know that anxiety can also disguise itself as anger? Anger can be a way to shield you from stressful thoughts. By raging at someone else, you can blame your anxious feelings on an outside force. And if you’re always moving, you don’t have time to ruminate on anxious thoughts. But neither response is healthy or helpful in the long term. When you feel agitated and restless more often than not, when you can’t stop moving and get easily annoyed or are prone to snap at people, you may have a serious problem with anxiety.
6. Panic Attacks
Often people mistake a panic attack for a heart attack. Tightness in your chest, rapid heartbeat, sweating and shaking, shortness of breath, and an upset stomach can easily be mistaken for a heart attack. It’s important to know the symptoms of a heart attackso that you don’t dismiss one by thinking it’s a panic attack or do the opposite and call 911 when you should call a psychologist. Frequent panic attacks are a sign you may have a panic disorder.
To differentiate between healthy and unhealthy anxiety, ask yourself: Is this manageable? If your anxiety keeps you from sleeping, working, social interactions, or errands, you may want to reach out to a therapist. If you feel anxious more than half the week for six months or longer, it’s probably time to seek help.
“Doing it yourself is a fad in the United States.” These were the first words in my first book in psychology, which I coauthored more than 40 years ago. Turns out we were wrong. Doing it yourself is not a fad, but a way of life in the U.S. These days we have so many more resources available to help us help ourselves, including self-help blogs like this one. And, of course, YouTube, which is a wonderful resource for training videos. I’ve turned to YouTube to learn the basics of such tasks as caulking a bathroom tub and repairing a hinge on kitchen cabinets. There’s pride in doing things yourself, even if the quality of the work may not match that of a professional. But I would draw the line at developing a winning tennis serve by following a self-instructional tutorial. Sometimes a good coach is needed. There is also a line to be drawn between using the Internet for self-help—even blogs like this—and seeking professional help.
My first book in the field focused on applying principles of behavior therapy to problems in living, from losing excess weight to smoking cessation to overcoming fears and sexual problems. For many of the problems people encounter in their daily lives, behavior therapy offered practical solutions. This blog continues in that tradition, offering tips for changing your thoughts and attitudes to change your life. We have explored how to rethink your responses to life’s twists and turns, and along the way offered tips on a range of troubling emotions, from overcoming worry and guilt to coping with fear and managing anger. We applied the wisdom of ancient Greece to “know thyself” by turning inwardly to examine and evaluate our thoughts and beliefs, especially the negative thoughts that underlie emotional problems like anxiety, depression, and anger. We confronted the two worthless emotions, worry and guilt—worthless because we don’t need to be wracked with guilt to recognize our mistakes and correct them or to be consumed with worry to take steps to protect ourselves from impending threats.
Self-Care Is Self-Help
With all this emphasis on self-help, we can lose sight of the importance of a basic principle of self-care—seeking help from others when help is needed. But how do you know when going it alone is just not cutting it? The benchmark clinicians typically use is whether problems are persistent and cause significant emotional stress or impair daily functioning. If you regularly struggle to get out of bed and get going in the morning because you’re feeling down in the dumps, your state of mind is affecting your ability to function effectively. If you can’t shake off intrusive worrisome or guilt thoughts, or if angry outbursts damage your relationships with others, or if you are continually on edge and can’t sleep at night or relax during the day, then it’s clear your daily functioning is impaired.
Where to Turn for Help
In the forty or so years I’ve been in practice, I’ve witnessed many changes in the field, including the emergence of cognitive behavioral therapy (CBT) as the leading modality of psychotherapy in use today. When I began my practice, psychodynamic therapists schooled in the Freudian and neo-Freudian traditions dominated the field. Today, there are many different forms of therapy and many different types of therapists, from psychologists and psychiatrists to mental health counselors and clinical social workers. Some forms of therapy, like CBT, offer briefer and more problem-focused treatment approaches than traditional therapies, such as psychoanalysis. CBT has become the treatment of choice for a range of psychological problems from phobias to social anxiety to insomnia, and evidence from controlled trials shows that CBT more than holds its own when stacked up against other therapies for treating depression and other emotional disorders and when compared to psychiatricmedication.
Over the years, the field of psychiatry has become increasingly medicalized, as psychiatrists (medical doctors with specialized training in psychiatry) largely turned from practicing psychotherapy toward medication management. Though psychiatric drugs have important roles to play in the treatment of mental health disorders, especially so with more severe disorders such as bipolar disorder and schizophrenia, popping a pill does not help people solve problems in their daily lives or learn skills they need to change how they think or improve their relationships with others. Moreover, relapse rates are high when patients stop taking psychiatric meds, and for good reason, as these drugs help manage symptoms but do not address underlying emotional or interpersonal problems. On the other hand, patients can carry the techniques they learn in psychotherapy well beyond the course of treatment and continue to apply them in their daily lives.
Am I Ready to Reach Out? A 10-Item Checklist
If you’re thinking about whether it makes sense to seek help from a professional, you may find the following checklist to be a useful guide. There is no set number of items that determine whether you could benefit from seeking help. But as a general guideline, answering at least a few of these questions in the affirmative suggests it might be helpful to talk to a psychologist or other mental health professional.
Yes or No? (You be the Judge)
1. Are my efforts to change my thinking or attitudes working?
2. Do I continue to struggle with anxiety, depression, or other negative feelings that impact my daily functioning?
3. Am I able to step back and examine my own thoughts, or would it help to have another person’s perspective?
4. Do I give up too easily rather than persevere in changing my thoughts and behaviors?
5. Are other people telling me I would benefit from “talking to somebody”?
6. Are worries making it difficult to sleep or function effectively during the day?
7. Am I avoiding situations out of fear or anxiety?
8. Is my behavior affecting my relationships in negative ways?
9. Do I find it difficult to make changes on my own or to stick with them?
10. Might I work better with a professional than going it alone?
Finding a Therapist
If you do decide to seek help, select a therapist who best fits your needs. Do you want to work with a therapist who uses psychological methods of treatment, such as a psychologist or counselor, or would benefit more from psychiatric medication prescribed by a psychiatrist?
Find a practitioner with the appropriate licensure and credentials—for example, a licensed psychologist, or a licensed psychologist holding advanced credentials (e.g., a Diplomate in Clinical Psychology awarded by the American Board of Professional Psychology, or ABPP), or a board-certified psychiatrist. Find out whether your medical insurance covers mental health services (check it out with your health care provider) and whether are you covered for out-of-network providers. As with other specialists, you may need to pay the therapist’s fee upfront and be reimbursed afterwards if the services are covered by your insurance plan, less any deductibles, co-pays, and so on.
Word of mouth is a good source for finding a therapist but be aware that what works well for one person might not work for another. You might also “google” the practitioner to see if anything untoward turns up or ask your state licensing board if there are any complaints filed against the individual. Be prepared to ask a potential therapist a lot of questions, like whether the therapist is experienced in treating people with similar problems as your own, what specific form of treatment will be used and what evidence supports its effectiveness, how long treatment is expected to last, what adverse experiences might be expected, such as drug side-effects, whether you are responsible for cancellation fees, and so on. Licensed professionals will openly discuss these and other questions with potential clients. If they balk, take that as a sign to look for someone else.
Whether you try going it alone or reaching out for help, the good news is that there is a range of effective therapeutic techniques that can help people live happier and more fulfilling lives.
The first sign that something is happening is Angelina’s hands. As she chats to the nurse in Italian, she begins to gesticulate, jabbing, moulding and circling the air with her fingers. As the minutes pass and Angelina becomes increasingly animated, I notice a musicality to her voice that I’m sure wasn’t there earlier. The lines in her forehead seem to be softening, and the pursing and stretching of her lips and the crinkling of her eyes tell me as much about her mental state as any interpreter could.Angelina is coming to life, precisely as my body is beginning to shut down. It’s 2am, and we’re sat in the brightly lit kitchen of a Milanese psychiatric ward, eating spaghetti. There’s a dull ache behind my eyes, and I keep on zoning out, but Angelina won’t be going to bed for at least another 17 hours, so I’m steeling myself for a long night. In case I doubted her resolve, Angelina removes her glasses, looks directly at me, and uses her thumbs and forefingers to pull open the wrinkled, grey-tinged skin around her eyes. “Occhi aperti,” she says. Eyes open.This is the second night in three that Angelina has been deliberately deprived of sleep. For a person with bipolar disorder who has spent the past two years in a deep and crippling depression, it may sound like the last thing she needs, but Angelina – and the doctors treating her – hope it will be her salvation. For two decades, Francesco Benedetti, who heads the psychiatry and clinical psychobiology unit at San Raffaele Hospital in Milan, has been investigating so-called wake therapy, in combination with bright light exposure and lithium, as a means of treating depression where drugs have often failed. As a result, psychiatrists in the USA, the UK and other European countries are starting to take notice, launching variations of it in their own clinics. These ‘chronotherapies’ seem to work by kick-starting a sluggish biological clock; in doing so, they’re also shedding new light on the underlying pathology of depression, and on the function of sleep more generally.“Sleep deprivation really has opposite effects in healthy people and those with depression,” says Benedetti. If you’re healthy and you don’t sleep, you’ll feel in a bad mood. But if you’re depressed, it can prompt an immediate improvement in mood, and in cognitive abilities. But, Benedetti adds, there’s a catch: once you go to sleep and catch up on those missed hours of sleep, you’ll have a 95 per cent chance of relapse.The antidepressant effect of sleep deprivation was first published in a report in Germany in 1959. This captured the imagination of a young researcher from Tübingen in Germany, Burkhard Pflug, who investigated the effect in his doctoral thesis and in subsequent studies during the 1970s. By systematically depriving depressed people of sleep, he confirmed that spending a single night awake could jolt them out of depression.
Benedetti became interested in this idea as a young psychiatrist in the early 1990s. Prozac had been launched just a few years earlier, hailing a revolution in the treatment of depression. But such drugs were rarely tested on people with bipolar disorder. Bitter experience has since taught Benedetti that antidepressants are largely ineffective for people with bipolar depression anyway.
His patients were in desperate need of an alternative, and his supervisor, Enrico Smeraldi, had an idea up his sleeve. Having read some of the early papers on wake therapy, he tested their theories on his own patients, with positive results. “We knew it worked,” says Benedetti. “Patients with these terrible histories were getting well immediately. My task was finding a way of making them stay well.”
So he and his colleagues turned to the scientific literature for ideas. A handful of American studies had suggested that lithium might prolong the effect of sleep deprivation, so they investigated that. They found that 65 per cent of patients taking lithium showed a sustained response to sleep deprivation when assessed after three months, compared to just 10 per cent of those not taking the drug.
Since even a short nap could undermine the efficacy of the treatment, they also started searching for new ways of keeping patients awake at night, and drew inspiration from aviation medicine, where bright light was being used to keep pilots alert. This too extended the effects of sleep deprivation, to a similar extent as lithium.
“We decided to give them the whole package, and the effect was brilliant,” says Benedetti. By the late 1990s, they were routinely treating patients with triple chronotherapy: sleep deprivation, lithium and light. The sleep deprivations would occur every other night for a week, and bright light exposure for 30 minutes each morning would be continued for a further two weeks – a protocol they continue to use to this day. “We can think of it not as sleep-depriving people, but as modifying or enlarging the period of the sleep–wake cycle from 24 to 48 hours,” says Benedetti. “People go to bed every two nights, but when they go to bed, they can sleep for as long as they want.”
San Raffaele Hospital first introduced triple chronotherapy in 1996. Since then, it has treated close to a thousand patients with bipolar depression – many of whom had failed to respond to antidepressant drugs. The results speak for themselves: according to the most recent data, 70 per cent of people with drug-resistant bipolar depression responded to triple chronotherapy within the first week, and 55 per cent had a sustained improvement in their depression one month later.
And whereas antidepressants – if they work – can take over a month to have an effect, and can increase the risk of suicide in the meantime, chronotherapy usually produces an immediate and persistent decrease in suicidal thoughts, even after just one night of sleep deprivation.
Angelina was first diagnosed with bipolar disorder 30 years ago, when she was in her late 30s. The diagnosis followed a period of intense stress: her husband was facing a tribunal at work, and they were worried about having enough money to support themselves and the kids. Angelina fell into a depression that lasted nearly three years. Since then, her mood has oscillated, but she’s down more often than not. She takes an arsenal of drugs – antidepressants, mood stabilisers, anti-anxiety drugs and sleeping tablets – which she dislikes because they make her feel like a patient, even though she acknowledges this is what she is.
If I’d met her three days ago, she says, it’s unlikely I would have recognised her. She didn’t want to do anything, she’d stopped washing her hair or wearing make-up, and she stank. She also felt very pessimistic about the future. After her first night of sleep deprivation, she’d felt more energetic, but this largely subsided after her recovery sleep. Even so, today she felt motivated enough to visit a hairdresser in anticipation of my visit. I compliment her appearance, and she pats her dyed, golden waves, thanking me for noticing.
At 3am, we move to the light room, and entering is like being transported forward to midday. Bright sunlight streams in through the skylights overhead, falling on five armchairs, which are lined up against the wall. This is an illusion, of course – the blue sky and brilliant sun are nothing more than coloured plastic and a very bright light – but the effect is exhilarating nonetheless. I could be sitting on a sun lounger at midday; the only thing missing is the heat.
When I’d interviewed her seven hours earlier, with the help of an interpreter, Angelina’s face had remained expressionless as she’d replied. Now, at 3.20am, she is smiling, and even beginning to initiate a conversation with me in English, which she’d claimed not to speak. By dawn, Angelina’s telling me about the family history she’s started writing, which she’d like to pick up again, and inviting me to stay with her in Sicily.
How could something as simple as staying awake overnight bring about such a transformation? Unpicking the mechanism isn’t straightforward: we still don’t fully understand the nature of depression or the function of sleep, both of which involve multiple areas of the brain. But recent studies have started to yield some insights.
The brain activity of people with depression looks different during sleep and wakefulness than that of healthy people. During the day, wake-promoting signals coming from the circadian system – our internal 24-hour biological clock – are thought to help us resist sleep, with these signals being replaced by sleep-promoting ones at night. Our brain cells work in cycles too, becoming increasingly excitable in response to stimuli during wakefulness, with this excitability dissipating when we sleep. But in people with depression and bipolar disorder, these fluctuations appear dampened or absent.
Depression is also associated with altered daily rhythms of hormone secretion and body temperature, and the more severe the illness, the greater the degree of disruption. Like the sleep signals, these rhythms are also driven by the body’s circadian system, which itself is driven by a set of interacting proteins, encoded by ‘clock genes’ that are expressed in a rhythmic pattern throughout the day. They drive hundreds of different cellular processes, enabling them to keep time with one another and turn on and off. A circadian clock ticks in every cell of your body, including your brain cells, and they are coordinated by an area of the brain called the suprachiasmatic nucleus, which responds to light.
“When people are seriously depressed, their circadian rhythms tend to be very flat; they don’t get the usual response of melatonin rising in the evening, and the cortisol levels are consistently high rather than falling in the evening and the night,” says Steinn Steingrimsson, a psychiatrist at Sahlgrenska University Hospital in Gothenburg, Sweden, who is currently running a trial of wake therapy.
Recovery from depression is associated with a normalisation of these cycles. “I think depression may be one of the consequences of this basic flattening of circadian rhythms and homeostasis in the brain,” says Benedetti. “When we sleep-deprive depressed people, we restore this cyclical process.”
But how does this restoration come about? One possibility is that depressed people simply need added sleep pressure to jump-start a sluggish system. Sleep pressure – our urge to sleep – is thought to arise because of the gradual release of adenosine in the brain. It builds up throughout the day and attaches to adenosine receptors on neurons, making us feel drowsy. Drugs that trigger these receptors have the same effect, whereas drugs that block them – such as caffeine – make us feel more awake.
To investigate whether this process might underpin the antidepressant effects of prolonged wakefulness, researchers at Tufts University in Massachusetts took mice with depression-like symptoms and administered high doses of a compound that triggers adenosine receptors, mimicking what happens during sleep deprivation. After 12 hours, the mice had improved, measured by how long they spent trying to escape when forced to swim or when suspended by their tails.
We also know sleep deprivation does other things to the depressed brain. It prompts changes in the balance of neurotransmitters in areas that help to regulate mood, and it restores normal activity in emotion-processing areas of the brain, strengthening connections between them.
And as Benedetti and his team discovered, if wake therapy kick-starts a sluggish circadian rhythm, lithium and light therapy seem to help maintain it. Lithium has been used as a mood stabiliser for years without anyone really understanding how it works, but we know it boosts the expression of a protein, called Per2, that drives the molecular clock in cells.
Bright light, meanwhile, is known to alter the rhythms of the suprachiasmatic nucleus, as well as boosting activity in emotion-processing areas of the brain more directly. Indeed, the American Psychiatric Association states that light therapy is as effective as most antidepressants in treating non-seasonal depression.
In spite of its promising results against bipolar disorder, wake therapy has been slow to catch on in other countries. “You could be cynical and say it’s because you can’t patent it,” says David Veale, a consultant psychiatrist at the South London and Maudsley NHS Foundation Trust.
Certainly, Benedetti has never been offered pharmaceutical funding to carry out his trials of chronotherapy. Instead, he has – until recently – been reliant on government funding, which is often in short supply. His current research is being funded by the EU. Had he followed the conventional route of accepting industry money to run drug trials with his patients, he quips, he probably wouldn’t be living in a two-bedroom apartment and driving a 1998 Honda Civic.
The bias towards pharmaceutical solutions has kept chronotherapy below the radar for many psychiatrists. “A lot of people just don’t know about it,” says Veale.
It’s also difficult to find a suitable placebo for sleep deprivation or bright light exposure, which means that large, randomised placebo-controlled trials of chronotherapy haven’t been done. Because of this, there’s some scepticism about how well it really works. “While there is increasing interest, I don’t think many treatments based on this approach are yet routinely used – the evidence needs to be better and there are some practical difficulties in implementing things like sleep deprivation,” says John Geddes, a professor of epidemiological psychiatry at the University of Oxford.
Even so, interest in the processes underpinning chronotherapy is beginning to spread. “Insights into the biology of sleep and circadian systems are now providing promising targets for treatment development,” says Geddes. “It goes beyond pharmaceuticals – targeting sleep with psychological treatments might also help or even prevent mental disorders.”
In the UK, the USA, Denmark and Sweden, psychiatrists are investigating chronotherapy as a treatment for general depression. “A lot of the studies that have been done so far have been very small,” says Veale, who is currently planning a feasibility study at Maudsley Hospital in London. “We need to demonstrate that it is feasible and that people can adhere to it.”
So far, what studies there have been have produced mixed results. Klaus Martiny, who researches non-drug methods for treating depression at the University of Copenhagen in Denmark, has published two trials looking at the effects of sleep deprivation, together with daily morning bright light and regular bedtimes, on general depression. In the first study, 75 patients were given the antidepressant duloxetine, in combination with either chronotherapy or daily exercise. After the first week, 41 per cent of the chronotherapy group had experienced a halving of their symptoms, compared to 13 per cent of the exercise group. And at 29 weeks, 62 per cent of the wake therapy patients were symptom-free, compared to 38 per cent of those in the exercise group.
In Martiny’s second study, severely depressed hospital inpatients who had failed to respond to antidepressant drugs were offered the same chronotherapy package as an add-on to the drugs and psychotherapy they were undergoing. After one week, those in the chronotherapy group improved significantly more than the group receiving standard treatment, although in subsequent weeks the control group caught up.
No one has yet compared wake therapy head-to-head with antidepressants; neither has it been tested against bright light therapy and lithium alone. But even if it’s only effective for a minority, many people with depression – and indeed psychiatrists – may find the idea of a drug-free treatment attractive.
“I’m a pill pusher for a living, and it still appeals to me to do something that doesn’t involve pills,” says Jonathan Stewart, a professor of clinical psychiatry at Columbia University in New York, who is currently running a wake therapy trial at New York State Psychiatric Institute.
Unlike Benedetti, Stewart only keeps patients awake for one night: “I couldn’t see a lot of people agreeing to stay in hospital for three nights, and it also requires a lot of nursing and resources,” he says. Instead, he uses something called sleep phase advance, where on the days after a night of sleep deprivation, the time the patient goes to sleep and wakes up is systematically brought forward. So far, Stewart has treated around 20 patients with this protocol, and 12 have shown a response – most of them during the first week.
It may also work as a prophylactic: recent studies suggest that teenagers whose parents set – and manage to enforce – earlier bedtimes are less at risk of depression and suicidal thinking. Like light therapy and sleep deprivation, the precise mechanism is unclear, but researchers suspect a closer fit between sleep time and the natural light–dark cycle is important.
But sleep phase advance has so far failed to hit the mainstream. And, Stewart accepts, it’s not for everybody. “For those for whom it works, it’s a miracle cure. But just as Prozac doesn’t get everyone better who takes it, neither does this,” he says. “My problem is that I have no idea ahead of time who it’s going to help.”
Depression can strike anyone, but there’s mounting evidence that genetic variations can disrupt the circadian system to make certain people more vulnerable. Several clock gene variations have been associated with an elevated risk of developing mood disorders.
Stress can then compound the problem. Our response to it is largely mediated through the hormone cortisol, which is under strong circadian control, but cortisol itself also directly influences the timing of our circadian clocks. So if you have a weak clock, the added burden of stress could be enough to tip your system over the edge.
Indeed, you can trigger depressive symptoms in mice by repeatedly exposing them to a noxious stimulus, such as an electric shock, from which they can’t escape – a phenomenon called learned helplessness. In the face of this ongoing stress, the animals eventually just give up and exhibit depression-like behaviours. When David Welsh, a psychiatrist at the University of California, San Diego, analysed the brains of mice that had depressive symptoms, he found disrupted circadian rhythms in two critical areas of the brain’s reward circuit – a system that’s strongly implicated in depression.
But Welsh has also shown that a disturbed circadian system itself can cause depression-like symptoms. When he took healthy mice and knocked out a key clock gene in the brain’s master clock, they looked just like the depressed mice he’d been studying earlier. “They don’t need to learn to be helpless, they are already helpless,” Welsh says.
So if disrupted circadian rhythms are a likely cause of depression, what can be done to prevent rather than treat them? Is it possible to strengthen your circadian clock to increase psychological resilience, rather than remedy depressive symptoms by forgoing sleep?
Martiny thinks so. He is currently testing whether keeping a more regular daily schedule could prevent his depressed inpatients from relapsing once they’ve recovered and are released from the psychiatric ward. “That’s when the trouble usually comes,” he says. “Once they’re discharged their depression gets worse again.”
Peter is a 45-year-old care assistant from Copenhagen who has battled with depression since his early teens. Like Angelina and many others with depression, his first episode followed a period of intense stress and upheaval. His sister, who more or less brought him up, left home when he was 13, leaving him with an uninterested mother and a father who also suffered from severe depression. Soon after that, his father died of cancer – another shock, as he’d kept his prognosis hidden until the week before his death.
Peter’s depression has seen him hospitalised six times, including for a month last April. “In some ways being in hospital is a relief,” he says. However, he feels guilty about the effect it has on his sons, aged seven and nine. “My youngest boy said he cried every night I was in hospital, because I wasn’t there to hug him.”
So when Martiny told Peter about the study he had just started recruiting for, he readily agreed to participate. Dubbed ‘circadian-reinforcement therapy’, the idea is to strengthen people’s circadian rhythms by encouraging regularity in their sleep, wake, meal and exercise times, and pushing them to spend more time outdoors, exposed to daylight.
For four weeks after leaving the psychiatric ward in May, Peter wore a device that tracked his activity and sleep, and he completed regular mood questionnaires. If there was any deviation in his routine, he would receive a phone call to find out what had happened.
When I meet Peter, we joke about the tan lines around his eyes; obviously, he’s been taking the advice seriously. He laughs: “Yes, I’m getting outdoors to the park, and if it’s nice weather, I take my children to the beach, for walks, or to the playground, because then I will get some light, and that improves my mood.”
Those aren’t the only changes he’s made. He now gets up at 6 every morning to help his wife with the children. Even if he’s not hungry he eats breakfast: typically, yoghurt with muesli. He doesn’t take naps and tries to be in bed by 10pm. If Peter does wake up at night, he practises mindfulness – a technique he picked up in hospital.
Martiny pulls up Peter’s data on his computer. It confirms the shift towards earlier sleep and wake times, and shows an improvement in the quality of his sleep, which is mirrored by his mood scores. Immediately after his release from hospital, these averaged around 6 out of 10. But after two weeks they’d risen to consistent 8s or 9s, and one day, he even managed a 10. At the beginning of June, he returned to his job at the care home, where he works 35 hours a week. “Having a routine has really helped me,” he says.
So far, Martiny has recruited 20 patients to his trial, but his target is 120; it’s therefore too soon to know how many will respond the same way as Peter, or indeed, if his psychological health will be maintained. Even so, there’s mounting evidence that good sleep routine can help our mental wellbeing. According to a study published in Lancet Psychiatry in September 2017 – the largest randomised trial of a psychological intervention to date – insomniacs who underwent a ten-week course of cognitive behavioural therapy to address their sleep problems showed sustained reductions in paranoia and hallucinatory experiences as a result. They also experienced improvements in symptoms of depression and anxiety, fewer nightmares, better psychological wellbeing and day-to-day functioning, and they were less likely to experience a depressive episode or anxiety disorder during the course of the trial.
Sleep, routine and daylight. It’s a simple formula, and easy to take for granted. But imagine if it really could reduce the incidence of depression and help people to recover from it more quickly. Not only would it improve the quality of countless lives, it would save health systems money.
In the case of wake therapy, Benedetti cautions that it isn’t something people should try to administer to themselves at home. Particularly for anyone who has bipolar disorder, there’s a risk of it triggering a switch into mania – although in his experience, the risk is smaller than that posed by taking antidepressants. Keeping yourself awake overnight is also difficult, and some patients temporarily slip back into depression or enter a mixed mood state, which can be dangerous. “I want to be there to speak about it to them when it happens,” Benedetti says. Mixed states often precede suicide attempts.
A week after spending the night awake with Angelina, I call Benedetti to check her progress. He tells me that after the third sleep deprivation, she experienced a full remission in her symptoms and returned to Sicily with her husband. That week, they were due to be marking their 50th wedding anniversary. When I’d asked her if she thought her husband would notice any change in her symptoms, she’d said she hoped he’d notice the change in her physical appearance.
Hope. After she has spent more than half her life without it, I suspect its return is the most precious golden anniversary gift of all.
This article first appeared on Mosaic and is republished here under a Creative Commons licence.
Many forms therapy and spiritual practice speak of mindfulness. Dispositional mindfulness (sometimes known as trait mindfulness) is a type of consciousness that has only recently been given serious research considerations.
It is defined as a keen awareness and attention to our thoughts and feelings in the present moment, and the research shows that the ability to engage in this prime intention has many physical, psychological, and cognitive benefits.
Mindfulness meditation is different. It has taken the Buddhist practice of mindfulness and introduced it to the western world as a form of preparing and training. Those who practice mindfulness meditation are often encouraged to have a “sitting practice,” where they have set aside time to meditate.
In the West, this practice is considered a means to an end. We will be calmer, have lower blood pressure, better relationships, and less stress if we use this practice. While all this is true, the mindfulness aspect of this practice — the essence of this style of meditation was not designed as a means to an end — it was designed to be a way of conscious living.
Mindfulness, when viewed in this way, becomes a quality in our life — a trait, not a state we enter into during practice.
Don’t get me wrong — mindfulness meditation and the wide variety of training programs and opportunities are all valuable exercises. But the original intention of mindfulness and the science now surrounding dispositional mindfulness may be at the very root of how we maintain hope, perseverance, and mental health.
Here is a sample of the research outcomes from nearly 100 studies using dispositional mindfulness:
This is an impressive list as the intervention we are talking about is a non-judging awareness of our thoughts and actions. The non-judgment is an important aspect of this practice. Cultivating a witness, a self that views our own experience with a benevolent prospective, has importance and impact.
This means that even before we attempt to change our thoughts, there is value — exceptional value — in simply noticing them.
This wobbly space between perception and response becomes clearer once we are given permission to examine the gap. Dispositional mindfulness is an invitation to widen that gap simply by noticing it exists. As we step back from our moment-to-moment experience we are cultivating our mindfulness, which then opens the way to responsiveness and the possibility and potential to shift our perceptions for the better.
As the Beat poet Alan Ginsberg suggested, one way to enter this gap is to “notice what you notice.” The practice is simple enough. As you survey your thoughts, feelings, and behaviors in a present moment try to do so without judgment. This pause for thought is, in itself, the very dispositional mindfulness that research is showing has so many benefits.
In essence, the practice is strengthened when we catch ourselves thinking.
As a psychiatrist, I often hear from my patients during their initial visit about how long they’ve been putting off seeing a psychiatrist out of fear. They also talk about how nervous they were leading up to the appointment.
First, if you’ve taken that major step to set an appointment, I commend you because I know it’s not an easy thing to do. Second, if the thought of attending your first psychiatry appointment has you stressing, one way to help tackle this is knowing what to expect ahead of time.
This can be anything from coming prepared with your full medical and psychiatric history to being open to the fact that your first session may evoke certain emotions — and knowing that this is totally OK.
So, if you’ve made your first appointment with a psychiatrist, read below to find out what you can expect from your first visit, in addition to tips to help you prep and feel more at ease.
Come prepared with your medical history
You’ll be asked about your medical and psychiatric history — personal and family — so be prepared by bringing the following:
a complete list of medications, in addition to psychiatric medications
a list of any and all psychiatric medications you might have tried in the past, including how long you took them for
your medical concerns and any diagnoses
family history of psychiatric issues, if there are any
Also, if you’ve seen a psychiatrist in the past, it’s very helpful to bring a copy of those records, or have your records sent from the previous office to the new psychiatrist you’ll be seeing.
Be prepared for the psychiatrist to ask you questions
Once you’re in your session, you can expect that the psychiatrist will ask you the reason you’re coming in to see them. They might ask in a variety of different ways, including:
“So, what brings you in today?”
“Tell me what you’re here for.”
“How’re you doing?”
“How can I help you?”
Being asked an open-ended question might make you nervous, especially if you don’t know where to begin or how to start. Take heed in knowing that there’s truly no wrong way to answer and a good psychiatrist will guide you through the interview.
If, however, you want to come prepared, be sure to communicate what you’ve been experiencing and also, if you feel comfortable, share the goals you’d like to achieve from being in treatment.
It’s OK to experience different emotions
You may cry, feel awkward, or experience various kinds of emotions while discussing your concerns, but know that it’s completely normal and fine.
Being open and sharing your story takes a lot of strength and courage, which can feel emotionally exhausting, especially if you’ve suppressed your emotions for quite a long time. Any standard psychiatry office will have a box of tissues, so don’t hesitate to use them. After all, that’s what they’re there for.
Some of the questions asked about your history may bring up sensitive issues, such as history of trauma or abuse. If you don’t feel comfortable or ready to share, please know that it’s OK to let the psychiatrist know that it’s a sensitive topic and that you’re not ready to discuss the issue in further detail.
You’ll work towards creating a plan for the future
Since most psychiatrists generally provide medication management, options for treatment will be discussed at the end of your session. A treatment plan may consist of:
referrals for psychotherapy
level of care needed, for example, if more intensive care is needed to appropriately address your symptoms, options to find an appropriate treatment program will be discussed
any recommended labs or procedures such as baseline tests prior to starting medications or tests to rule out any possible medical conditions that may contribute to symptoms
If you have any questions about your diagnosis, treatment, or wish to share any concerns you have, be sure to communicate them at this point before the end of the session.
Your first psychiatrist might not be the one for you
Even though the psychiatrist leads the session, go in with the mentality that you’re meeting your psychiatrist to see if they’re the right fit for you as well. Keep in mind that the best predictor of successful treatment depends on the quality of the therapeutic relationship.
So, if the connection doesn’t evolve over time and you don’t feel your issues are being addressed, at that point you can search for another psychiatrist and get a second opinion.
What to do after your first session
Often after the first visit, things will pop up in your mind that you wished you had asked. Take note of these things and be sure to write them down so you won’t forget to mention them next visit.
If you left your first visit feeling badly, know that building the therapeutic relationship may take more than one visit. So, unless your appointment turned out horrible and unredeemable, see how things go during the next few visits.
The bottom line
Feeling anxious about seeing a psychiatrist is a common feeling, but don’t let those fears interfere with you getting the help and treatment that you deserve and need. Having a general understanding of what kinds of questions will be asked and topics that will be discussed can definitely alleviate some of your concerns and make you feel more comfortable at your first appointment.
And remember, sometimes the first psychiatrist you see may not necessarily turn out to be the best fit for you. After all, this is your care and treatment — you deserve a psychiatrist who you feel comfortable with, who’s willing to answer your questions, and who will collaborate with you to achieve your treatment goals.
We’ve come a little way in reducing the stigma that’s associated with mental illness, but not nearly far enough.
Consider these results pulled from a public attitude survey in Tarrant County, Texas, conducted by the county’s Mental Health Connection and the University of North Texas in Denton to determine the community’s view of mental illness:
More than 50 percent believe major depression might be caused by the way someone was raised, while more than one in five believe it is “God’s will.”
More than 50 percent believe major depression might result from people “expecting too much from life,” and more than 40 percent believe it is the result of a lack of willpower.
More than 60 percent said an effective treatment for major depression is to “pull yourself together.”
Unfortunately, these beliefs are often held by those closest to us, by the very people from whom we so desperately want support.
Resenting them for their lack of understanding isn’t going to make things better, though. It almost always makes things worse. Whenever I hit a severe depressive episode, I am reminded once more that I can’t make people understand depression any more than I can make a person who hasn’t gone through labor understand the intense experience that is unique to that situation. Some people are able to respond with compassion to something that they don’t understand. But that is very rare.
Don’t Mistake Their Lack of Understanding for a Lack of Love
Whenever I try to open the doors of communication and express to a family member or friend how I am feeling, when I try to articulate to them the pain of depression, and am shut down, I usually come away extremely hurt. I immediately assume that they don’t want to hear it because they don’t love me. They don’t care enough about me to want to know how I am doing.
But distinguishing between the two is critical in maintaining a loving relationship with them. My husband explained this to me very clearly the other day. Just because someone doesn’t understand depression or the complexity of mood disorders doesn’t mean they don’t love me. Not at all. They just have no capability of wrapping their brain around an experience they haven’t had, or to a reality that is invisible, confusing, and intricate.
“I wouldn’t understand depression if I didn’t live with you,” he explained. “I would change the subject, too, when it comes up, because it’s very uncomfortable to a person who isn’t immersed in the daily challenges of the illness.”
This is a common mistake that many of us who are in emotional pain make. We assume that if a person loves us, he or she would want to be there for us, would want to hear about our struggle, and would want to make it better. We want more than anything for the person to say, “I’m so sorry. I hope you feel better soon.”
The fact that they aren’t able to do that, however, does not mean they don’t love us. It just means there is a cognitive block, if you will, on their part — a disconnect — that prevents them from comprehending things beyond the scope of their experience, and from things they can see, touch, taste, smell, and feel.
Don’t Take It Personally
It is incredibly difficult not to take a person’s lack of response or less-than-compassionate remark personally, but when we fall into this trap, we give away our power and become prey to other people’s opinions of us. “Don’t Take Anything Personally” is the second agreement of Don Miguel Ruiz’s classic The Four Agreements; the idea saves me from lots of suffering if I am strong enough to absorb the wisdom. He writes:
Whatever happens around you, don’t take it personally … Nothing other people do is because of you. It is because of themselves. All people live in their own dream, in their own mind; they are in a completely different world from the one we live in. When we take something personally, we make the assumption that they know what is in our world, and we try to impose our world on their world.
Even when a situation seems so personal, even if others insult you directly, it has nothing to do with you. What they say, what they do, and the opinions they give are according to the agreements they have in their own minds … Taking things personally makes you easy prey for these predators, the black magicians. They can hook you easily with one little opinion and feed you whatever poison they want, and because you take it personally, you eat it up ….
I have learned that when I fall into a dangerous place — when I am so low that mindfulness and other techniques that can be helpful for mild to moderate depression simply don’t work — I have to avoid, to the best of my ability, people who trigger feelings of self-loathing. For example, some people in my life adhere tightly to the law of attraction and the philosophies of the book The Secret by Rhonda Byrne that preach that we create our reality with our thoughts. They have been able to successfully navigate their emotions with lots of mind control and therefore have trouble grasping when mind control isn’t enough to pull someone out of a deep depression.
I struggle with this whenever I fall into a depressive episode, as I feel inherently weak and pathetic for not being able to pull myself out of my pain, even if it means simply not crying in front of my daughter, with the type of mind control they practice, or even mindfulness or attention to my thoughts. This, then, feeds the ruminations and the self-hatred, and I’m caught in a loop of self-flagellation.
Even if they aren’t thinking I’m a weak person, their philosophies trigger this self-denigration and angst in me, so it’s better to wait until I reach a place where I can embrace myself with self-compassion before I spend an afternoon or evening with them. If I do need to be with people who trigger toxic thoughts, I sometimes practice visualizations, like picturing them as children (they simply can’t understand the complexity of mood disorders), or visualizing myself as a stable water wall, untouched by their words that can rush over me.
Focus on the People Who Do Understand
In order to survive depression, we must concentrate on the people who DO get it and surround ourselves with that support, especially when we are fragile. I consider myself extremely lucky. I have six people who understand what I’m going through and are ready to dole out compassion whenever I dial up their numbers. I live with an extraordinary man who reminds me on a daily basis that I am a strong, persevering person and that I will get through this. Whenever my symptoms overtake me and I feel lost inside a haunted house of a brain, he reminds me that I have a five hundred pound gorilla on my back, and that my struggle doesn’t mean that I am a weak person not capable of mind control. At critical periods when I’m easily crushed by people’s perceptions of me, I must rely on the people in my life that truly get it. I must surround myself with folks who can pump me up and fill me with courage and self-compassion.
It is a well known fact that those that suffer from PTSD are at a much higher risk for falling into substance abuse. Many people with PTSD often find themselves going for the bottle or something else harmful to help quickly find relief from their pain. But could early substance abuse actually lead to PTSD? […]
According to many authorities, currently there is a mental healthcrisis. School shootings, workplace violence, random acts of violent rage, even some acts of terrorism have been associated with, and even blamed on, acute psychological distress, depression, or more frank mental illness. Data from the National Institute of Mental Health suggests that roughly 10 million individuals in the US suffer from some form of severe mental illness characterized by severe impairments to their daily lives. But it has been further estimated that up to another 30 million people may have to deal with psychological conditions that serve to mildly or moderately interfere with their ability to most effectively function socially or at the workplace. How does society begin to address such a problem when traditional approaches are sometimes disappointing?
Using psychological first aid (PFA) to foster resilience may be one nontraditional approach. This is the third in a series of three discussions of PFA. PFA may be defined as a supportive presence designed to achieve three goals: 1) stabilize (prevent acute stress from worsening) 2) mitigate (de-escalate and dampen acute distress) 3) advocate for and facilitate access to professional assistance, if necessary. Two previous discussions in this series have addressed the first and second goals. This discussion addresses the third goal, facilitating access to supportive psychological care, if needed.
EXPANDING THE REACH OF MENTAL HEALTH SUPPORT
Getting friends, family, and others for whom you care the psychological assistance they might need is not always easy. The first step is recognition. Family members, friends, co-workers, healthcare providers, and educators all have the potential to reduce the stigma associated with seeking mental health care. Furthermore, they have the potential to help others seek professional guidance when needed. This is achieved by serving as compassionate frontline advocates for the pursuit of such professional mental health support.
As noted, the first step to removing the stigma associated with seeking mental health support as well as expanding the reach of mental health services is recognition of the problem. Listed below is a sampling of psychological or behavioral patterns of concern. Recognition of signs and symptoms such as these is a foundation of PFA.
1. Depression: Everyone gets sad, but depression is another matter. The warning signs of a significant depressive episode may be a persistent sad mood for a couple of weeks combined with a loss of appetite, chronic fatigue, awakening early in the morning (often around 3am) with difficulty falling back to sleep, and a loss of libido. We become especially concerned when there is a questioning of the value of life, and the loss of hope or a future orientation as these may herald suicidal ideation and even self-injurious or suicidal acts. Professional care in such cases is imperative.
2. Debilitating Fear: Fear may be thought of as apprehension and stress arousal in response to a specific threat or challenge. Most people have fears of one kind or another. We become concerned when those fears become debilitating interfering with one’s personal or occupational lives. Persistent phobic (irrational fear) avoidance can be crippling. For example the fear and avoidance of crossing bridges or of flying can be quite debilitating.
3. Anxiety: Anxiety may be defined as apprehension and stress arousal in response to an ambiguous threat or challenge. Anxiety can be especially challenging because of its ill-defined nature. It too can be crippling. When it becomes so, it is time to seek a professional opinion.
4. Posttraumatic Stress and Posttraumatic Stress Disorder (PTSD):These are perhaps more correctly envisioned as posttraumatic stress injuries (PTSI): Stress following the exposure to a trauma, usually thought of as either direct or vicarious exposure to a life threatening experience, can be intense and disorienting, but that stress reaction usually diminishes within weeks and resolves within months. When one becomes acutely disabled or continues to vividly re-imagine the experience, becomes psychologically numb or depressed, and experiences irritability, anger, or impulsiveness which interferes with one’s personal or professional life for more than a few weeks, it is then important to seek professional assistance.
5. Strange, erratic, or self-debilitating behavior of any kind, including self-medication: In the final analysis, whether it is crippling depression, anxiety, phobic avoidance, posttraumatic stress reactions, or self-debilitating behavior of any kind that interferes with one’s happiness or personal and professional life, the guidance of a mental healthcare provider should be sought.
Beyond recognition, what else can be done? If you recognize a perceived need for professional mental health guidance or support in someone you care for, work with, supervise, or mentor, compassionate advocacy may be useful in facilitating access to such care. Listed below are some simple steps to assist.
1. Stressful life experiences can make one feel alone and overwhelmed. Make it clear there is no reason for anyone to endure distress alone.
2. Anticipate barriers to seeking professional support and be prepared to address them. Barriers include such things as stigma, a perception of weakness, or a misunderstanding about what mental health providers actually do. Help the person reinterpret getting help as a sign of personal strength, not a weakness. Reframe seeking professional guidance more as a means of fostering resilience, less as seeking treatment. Create a positive and hopeful expectation of improvement or recovery. Point out that delaying intervention can lead to a needlessly prolonged period of distress or inability to function effectively. Lastly, suggest that getting professional support is a sign of respect and concern for others, such as family, friends, and co-workers, as well as well, as themselves.
3. Be prepared to address practical and logistical concerns such as where and how to seek professional services. Be prepared to offer specific options about trusted providers, pastoral counseling options, telephone hotlines, financial counseling services, community-based mental health services, employee assistance programs, or other employer-based services.
4. Use encouragement in a compassionate and supportive manner, but be persistent in your encouragement.