A Short Guide to People Who Can Help With Your Mental Health

[Written by an American. Generalities probably apply to Canada and UK, specifics certainly do not]

>Can prescribe medicine related to mental health concerns
In the U.S., virtually all psychiatrists do not do psychotherapy on a long term basis. They’re expensive, usually have long waiting lists—I’m told it’s something like an expected three month wait to see a psychiatrist in my city—and specialize in medication.

If you are making an appointment to see a psychiatrist, this is frequently considered evidence that you are looking for medication. This can cause weird misunderstandings when people think of a psychiatrist and a psychologist as identical and psychiatrists anticipate that people who come to see them are coming to see them for their specialty. Patients can (and do!) occasionally get the impression that they’re hopeless and must go on medication or that the entire mental health establishment is focused on pushing drugs.

Psychiatric Nurse Practitioner/Mental Health Nurse Practitioner
>Can prescribe medication related to mental health concerns.
I’ve only run across these in hospitals, but this article suggests they also operate in private practice. In my experience they do slightly more therapy than the psychiatrists I know and work with, though their primary focus does seem to be medication management.*

Clinical Psychologist
>Cannot prescribe medicine.
Has a Ph.D or a Psy.D. Worked a variety of successive internships to collect enough hours (1,500 to 6,000, varied by state) to become a licensed psychologist. Almost always have specialized training in administration of specific kinds of therapies, like Cognitive Behavioral Therapy or Motivational Interviewing.

My impression is that psychologists are low variance in terms of skill at administering one-to-one therapy and diagnostic work. They’ve all received lots of hours of practice before being licensed, and while there are many ways to be a clinical psychologist who does therapy, there aren’t as many ways as say, a social worker. Psychologists are also more likely to be able to sort out a diagnostic label, if that’s relevant or important for you. Others on this list could, but might not use diagnostic labels as frequently or be as comfortable getting a really specific, precise diagnosis.

Social Worker
>Cannot prescribe medicine.
Most social workers who are providing one-on-one therapy have a Master’s degree**. Social work is weird because the list of things a social worker could be doing as their job is…….very long.

  • being available to talk when someone is in hospice
  • working in school with kids who are struggling (behaviorally, emotionally, academically)
  • doing therapy in a standard couch + office + “and how does that make you feel” setting
  • investigating reports of abuse or neglect
  • coordinating other therapists and psychiatrists for clients
  • talking to people who recently were diagnosed with a terminal or chronic illness
  • helping people get into detox programs by making a lot of phone calls
  • doing assessments of children entering juvenile detention
  • helping new immigrants or refugees adapt and find services
  • going to people’s homes to assist with counseling
  • helping people deal with other bureaucracies
  • accompanying clients to appointments (such as Social Security offices)
  • leading groups (support, therapy, social skills, etc)

The main differences I notice between social workers and psychologists are:

Variance: social workers are high-variance; I happened to spend both of my training internships doing individual therapy and training in Cognitive Behavioral Therapy. It would have been equally possible for me to graduate having never done one-on-one therapy and without specialized training in a single modality.

Advocacy & Case Management: Part of the reason for the high-variance nature of training is that some social workers never particularly want to do one-on-one therapy. They might prefer ‘case-management’. Ever needed to figure out how to get into a treatment center and also have follow-up services when you left? A case manager might coordinate all the people at the treatment center plus follow-up appointments, plus check in on your progress. It’s always been an expected part of my non-case manager role that I do some of this. Sometimes therapy is put on hold to figure out how a client is getting treatment for their health concerns, or sorting out billing. This seems to be a cultural difference between social work and the rest of the list.

Mental Health Counselor
>Cannot prescribe medicine (seeing a theme, yeah?)
Like a social worker, has a master’s level degree, plus two more years of work in the field to get an independent (not-requiring supervision) license. I usually see the license called an LMHC or CMHC. Can do similar roles as any of the non-prescribers listed above. Less of an advocacy focus than social work.

Marriage and Family Therapist
>Cannot prescribe medicine.
Though all previous listed professionals could do couples’ counseling, this category specializes in it, and other family work. Master’s level degree plus two years of training to get a license for independent (non-supervised) work.

*Know more? Feel free to add in the comments.

**It’s possible to be a social worker with a Bachelor’s degree, but this generally involves more case management and very little direct therapy.  Except in my state, where you do not have to have a degree at all.

Messy Psychiatric Medication

1. Psychiatric medication helps many* people who take it.

2. Psychiatric medication has side effects.

3. Many of these side effects are unpleasant-feeling enough to cause people to decide that they would rather not take medication, or to make it prohibitively hard to take medication on bad days.

3b. I mean, really frustrating side effects. Like “this medication dulls all my emotions” or “this medication makes me totally disinterested in sex and is screwing with my ability to maintain a relationship” or “this medication is supposed to help me interact better with society, except that it gives me involuntary movements and people can be jerks about that.”

4. This means that some people don’t take their medication consistently. For instance, people with schizophrenia have some of the lowest rates of medication adherence. (How much nonadherence, exactly, is debated, with a range you could drive a truck, two Hummers, and a party bus through. 20% to 89%? Really?)

5. Tachyphylaxis, that thing where your medication abruptly stops doing anything for you at all, is deeply unpleasant.

6. It’s easy enough to tell if, for instance, you’re experiencing fewer panic attacks, or if the hallucinations are milder. It’s not particularly easy to tell if, say, your depression is lifting. Only around half of the people I’ve known who went on antidepressants noticed an immediate change in their mood—even as friends and family did. Meanwhile, the side effects were hard to miss.

*Disclaimer for everyone (including me) who flinched at this. It helps many, but not all.


Empowerment Exhaustion

[CN: brief mention of self harm, anorexia, alcoholism]

Empowerment as a social service model holds that….well, it holds a lot of mostly-overlapping things actually. A handful of the places I’ve worked with have had empowerment models, which get summarized into catchphrases like “the client is the expert on what’s going on with them” and “we provide information; we don’t tell clients what to do.”

And I can almost hear the grumbling over here, so let me make a defense.

Lots of people who end up needing social services haven’t got many feelings of control over their lives. A feeling that you have control over your life (i.e. internal locus of control) is associated with lots of excellent mental health outcomes (Maltby, Day, McAskill, 2007)*. Empowerment might be teaching the client to have a sense of control and choice in their lives, which is a powerful lesson.

Empowerment models meet the client where they are. If Jimmy shows up in our office because a teacher reported that he was self-harming, and our response is that nobody should ever self harm ever again, well then Jimmy can reasonably conclude that we aren’t helpful or interested in why he self-harms, and proceed to dismiss us.

While we continue to suggest that he just stop doing that, Jimmy can go on his merry way ignoring us. We’ve missed the opportunity to reduce the harm to Jimmy at all (is he using clean razors? does he care for his cuts?) or figure out why Jimmy is using self-injury as a coping mechanism (is he depressed? are there interpersonal problems going on? Can we help with any of that?).

The empowerment model avoids pattern-matching to everyone else who tells the client what they should have done/aren’t smart enough to do/should be doing next. If Bob the Alcoholic shows up because his wife pressured him into seeing a substance abuse counselor and the counselor says something that sounds like “You drink too much!”…well.

Now the counselor just sounds like Bob’s wife. And Bob’s wife has been bugging him about drinking too much for a while—he’s gotten practice at ignoring people who say that! Besides, now it seems like the counselor is on his wife’s side, and people are not all that calm and thoughtful when they feel as though they’re being ganged up on. Feeling as though you and your therapist are on the same side is the best predictor of immediate outcome and roughly 8% percent of the outcome four years later.

You’ll notice that in both Bob and Jimmy’s cases, the client-as-expert framing isn’t meant to cause the conversation to stop when the client says they’re happy with the current state of affairs. (So, not: “The client says she’s happy getting high every afternoon—guess I’d better pack it in then!”) But instead, it assumes that the client is doing the current behavior because it feels adaptive…and might currently be adaptive.

A personal example: for most of the time I’ve had an eating disorder, up until a few years ago, eating a whole meal caused me to be panicky and anxious, unable to focus or sit still to work. At this point in recovery, I was able to usually force myself to do it, deal with being panicky for a while, and then go about my normal life. But, during midterms and final term papers, I needed to be working and focused almost all of the time. In the choice between skipping a few meals here and there and failing, I did the one that wouldn’t mean paying extra tuition to repeat whole classes.

One model for responding could have pointed out that this is known as anorexia, and it is not good for your health, Kate. I tried this! For a while I was chronically panicky during finals: freaking out when I ate food and tried to focus, feeling overwhelmingly guilty (I was failing at recovery!) when I didn’t. I had even more meltdowns, I was able to focus even less.

The other option pointed out that I did have some interest in continuing to eat food, but that this was harder to do during final exams. Sometimes the most adaptive option I had at hand, given my anorexia-brain was to eat very little food when I needed to focus for a long period of time. An empowerment model might point out that this is sometimes the only adaptive choice I have at hand…and then looks for  ways to decrease the instances where this is the only adaptive choice. Can I figure out what things make food the least stressful? Can I work on my midterms beginning much earlier, therefore allowing me to focus less each given day?

And this worked! It’s worked so well that it’s still my strategy: as soon as mid-semester rolls around I switch to having lots of enticing, low stress food around and I’m willing to settle for a lower grade if it means I have to force myself to focus a little less frequently each day.

….but actually, I don’t often enjoy when I’m on the receiving end of empowerment-based interventions. And this is probably because I’m not a good fit for them! By the time I end up on the client side of the couch, I’ve gotten to the point where I don’t think I’m currently making the best choices for myself on my own steam (that is, I’m decision fatigued).  Therefore, I’ve called in the therapist to help. And the conversations can feel like this:

Therapist: “I’m allowing you to determine what’s best for you, and give you control in a way that will empower you to make decisions in the future. Some options you have include, Options A, B, and C. ”

Me: “I’m here because you are trained to be the expert! I’m not able to currently trust decisions I make! None of the list of options seem obviously bad, but you have more knowledge about what happens in each scenario! Now I feel like I’m trying to read between the lines, when you could just tell me what tends to work for people with my particular issue.”

In fact, when I’m particularly anxious and decision fatigued, this resolves in irritation: “I do NOT care what my list of options are, I want an ANSWER about the BEST option right now.”

But I live in a world where I get to (mostly) make all of my own choices and (mostly) have everyone assume I am deserving of autonomy. It’s cool and interesting and ‘powerful’ when I am open about mental illness, rather than unavoidable or ‘gross’ or ‘disturbing’. I get to make my own choices…so much so that it’s sometimes exhausting! Empowerment approaches feel like they add to the mental work of choosing when I’m at my least capable. But if I never got treated as though I were capable of making my own choices? Or I stated my choices, and then people nodded a bit and said those were silly decisions that indicated I was clearly incapable? The empowerment style would probably feel incredible.

It reminds me a little of picking a restaurant with your friends. If you have three friends who never ever ask you where you’d like to go out to eat, or take into account the fact that you hate Thai food, the first time they say “Hey, Joe, where should we eat tonight?” it’ll be great! But if the four of you always trade off on picking restaurants, and one night, everyone says “Nah, I don’t care, I’ll eat whatever” and nobody picks a place to eat?  You’re going to be annoyed. (And hungry.)

Related, on both food and empowerment grounds: poverty and the marshmellow test

*there’s a mediating effect of coping skills, but the short version is that having an internal sense of control seems to be related to a large number of positive health and mental health outcomes.

Serious (Stucky) Advice

As all good internet stories go:

Once upon a time (last Sunday) I was reading fanfiction (this one) and I stumbled across something important, as explained by Bucky Barnes. (Look, you can have Shakespeare’s jokefic. I will read my emotional-pain heavy MCU fic). Ahem.

There’s a big war memorial in the park with both their names prominently inscribed. Rogers stands in front of it for 22 minutes their first day in the park. But there are no bugs on the workout gear, so if he says anything, Barnes doesn’t know.

It’s just past dawn, and a light frost tips the grass. It’s pretty but a reminder that no stores seem to carry any damn handkerchiefs. Barnes wipes his nose on his sleeve.

The fight with Stark brings the return of Rogers’s sad expression. Fucking Stark.

This is a particular difficulty of the mission: how to erase Rogers’s sadness while maintaining distance. How to suggest the comfort of a long bath or a grilled cheese with ham. A white mocha can fix almost anything for a little while.

Hey. Note: it is useful knowledge for living to have a list of things that are good no matter what.

No really, it’s very useful knowledge.

It’s hard to get up the momentum to get yourself  into a place where you can relax. Especially when you’re agitated, on edge, or anxious,* the last thing you want to do is stop and search through your mind for a solution. Similarly, when I’m sad, it’s easy to get stuck in a rut of “I’m sad. I’m still sad. I’m sad.” Better option: “I am allowed to feel sad, but while I do so, I’m going to be kind to myself and do things that make me feel good.” When I’m ready to stop feeling sad, I will be able to climb out of the rut.

To this end, I suggest creating a List of Things That Are Unambiguously Good.

Step 1: Set a timer for five minutes
Step 2: Spend those five minutes doing nothing but writing down things that make you feel good without drawbacks.
Step 3: Add to list as necessary, keep in a common location. I store my list in the program that holds my daily agenda, because it’s on my phone, computer, and tablet, and open constantly. It’s unlikely I’d be somewhere without access to the list, which in turn makes it likely that when I feel bad, I’ll use it.

My list is below, and you’re encouraged to steal or test any ideas that strike your fancy.

-Drinking sparkling water with orange juice.
-Painting my nails
-A very hot bath with books.
-Lighting a scented candle.
-Watching something on my Netflix queue
-Tea with milk and sugar
-Going for a walk
-Reviewing ‘happy things’ file on my computer.
-Wrapping up in blankets, especially heavy ones.
-Cute animals on tumblr
-Foot massages

*yes, these were synonyms. However, people seem to find recognition with some words and not others, so I use a variety. See also Julia’s excellent blog post.

Huge Linkpost: Self-Therapy Resources Edition

Friendly Formulation Worksheet
This is the worksheet I adapted to do a self-CBT exercise.

Last Sunday I gave a talk on doing therapy on yourself, as well as giving demonstrations of two different exercises—one from Cognitive Behavioral Therapy, one from Dialectical Behavioral Therapy, which were the modalities in the focus of my talk. CBT and DBT are not the only types of evidence based therapies (in fact, DBT is descended from CBT). However! I find that most self-help and/or manualized therapies that people run across are from Cognitive Behavioral or Dialectical roots, and that those who dislike CBT like DBT and vice versa.

None of the comments below should be taken as Official Therapeutic Advice. However, I made lots of recommendations based on reading and poking through all sorts of books and apps and exercises intended to teach self-therapy.

Except where otherwise noted, all are books or resources I’ve personally used, and all are compared to at least two other things I’ve tried and found inferior.

Non-Clinical Books

These are not the total of all books that are non-clinical and excellent. They are, however, books I have interacted with and found to be generally excellent.
Feeling Good
When Panic Attacks
CBT for Work

Clinical Books
I talked briefly about clinical books, which I recommend non-clinicians try out. They’re often more expensive, but usually extremely information-dense, tend to contain far more worksheets and exercises, and are usable to the layperson. My advice for reading them effectively: skip the theories (more on this in another post) and go straight to suggested questions and example interactions between therapist and client. The book is trying to teach a framework from which the clinician can adapt and pull from to interact with their client.

I usually find it most useful to read the book while imagining I am the clinician (clinical books facilitate this well) with a client in front of me with identical issues and history to mine. This both makes it more likely that I’ll take the outside view and forces me to avoid skipping aversive steps, which I notice I do more frequently when reading non-clinical books. So! below are my favorite clinical books:
Clinical Interviewing (here’s the endorsement for this one: I enthusiastically read this school textbook for fun and I don’t regret it one bit.)
Dialectical Behavioral Therapy for Borderline Personality Disorder (not just for people with BPD—I found the worksheets and handouts in this most useful for boundary-setting and interpersonal skill development)
DBT Workbook for Clients (Caveat: this is the only thing on the list that I have not vetted personally, though I have repeatedly been told by others I trust that it is wonderful)

Sources for Exercises and Worksheets:
For a massive variety of free-to-use worksheets, there’s psychology.tools.
I used this particular worksheet (slightly adapted) to create the CBT that I lead the group in doing. I chose it because it’s short, it ends on a positive note, and it explores a bunch of reasons as to why a problem could be persisting. It also capitalizes on the peak end effect.
Presumably from the makers of psychology.tools, there’s selfhelp.tools, a site that’s explicitly for use by non-clinicians.
Google Drive of CBT forms that have been made into Google forms!

Self-Help Anxiety Management Android, iOS (my review here)
Recovery Record (food + mood tracking)
T2 Mood Tracker Android, iOS

Note: since I gave this talk to rationalists, I included some specific notes for that community; mainly, what questions I ask when suggesting what kind of therapy someone might prefer. They are enclosed below. Again, not official advice.

1. Do you find meditation practices to be

(a)pleasant and useful or

2. When you have unpleasant emotions, do you prefer

(a)poking and digging into them and the root cause or
(b) focusing on causing them to dissipate?

3. If you have taken a CFAR workshop recently and took Val’s class on embodied cognition, etc, did the ‘feel your feet’ exercise make sense? Can you usually notice how you are occupying your body?
4. If you have read Gendlin’s Focusing, did the idea of a ‘felt-sense’ make sense to you? Were those exercises natural?

If (b),(a), No, and No, I suggest starting by looking at things described as CBT or cognitive therapy. If (a),(b), Yes, and Yes, I suggest starting with mindfulness/DBT first. Technically, DBT is a cognitive behavioral therapy. However, the ‘feel’ of things described mainly as CBT and the feel of DBT seem to be significantly different, with the latter being mindfulness/Zen/radical acceptance focused in a way that the former does not emphasize.

Name That Therapy

Or, Therapy Names as Currency

When my client says “Therapy sucks—I tried it and it didn’t work!” there are a number of things this could mean.

“The therapist I had was of a personality that did not mix with my personality well. I felt invaded and condescended to and it was deeply unpleasant.”

“The therapist tried a specific therapy: psychodynamic or DBT or narrative therapy, and it was [not my cup of tea/definitely making it worse/seriously not feasible for my life or personality]”

“Therapy as a modality is not very compatible with me. We should pursue alternate things like medication or structuring parts of my environment to decrease symptoms or finding me a support group.”

I am uncomfortable with you, New Therapist, and expressing it via saying that therapy sucks.

The thing is, I have none of that information, just that the client is not pleased about interacting we me and has low expectations. Though my next question is almost always going to be “can you tell me more about why it sucked for you?” Even presuming they answer and follow that line of questions (and this is not guaranteed), I won’t have a ton of information.

So this is a plea/suggestion/blog post request for therapists to err on the side of telling their clients what the heck they’re doing.* And a second suggestion for clients to ask their therapists what the plan is.

Consider this situation: you, client-named-Jeff, are going to therapy for the first time. You don’t have any prior interaction with psychotherapy, nor do you read blogs like this. Your therapist focuses on cognitive distortions and sends you home with homework, and you just hate it. It feels like being a kid, and you really wanted to figure out why you’re feeling so anxious all the time (you’ve wondered if it comes from having to move around so much when you were growing up).  You never end up with rapport with the therapist, and given that trusting and liking your therapist is an important component of therapeutic success…you decide that the cost of seeing a counselor is ridiculous, and leave.

Two years later, your anxiety is severely impairing your ability to function at work. The company you work for is small, and they offer to pay for therapy instead of asking you to resign, hoping that it will allow them to keep an employee who has a history of loyalty and service. So you end up in my office. “Therapy sucks,” you say. We spend a good deal of time trying to figure out what things you hate and what things I can do that don’t make you feel patronized. Eventually we build some kind of trust, but your opinion remains that most therapists are incompetent. Lots of time is wasted in hit-and-miss appointments.

Or, consider this scenario: you, client-named-Jeff, are going to therapy for the first time. Again, you don’t have prior info about what therapy is like. Your therapist tells you do that they do Cognitive Behavior Therapy. They focus on cognitive distortions and sends you home with homework, and you just hate it. As in the previous story, it feels silly and childish and you’re more interested in discussing how you ended up where you are and building from there.  The therapist hears your complaints, but for some reason doesn’t deviate much from the CBT framework.

Now two years later, I see you. In the course of trying to figure out why you think therapy is hell served in fifty minute portions, you mention that your previous therapist did CBT. Now, I have some pretty damn useful information. I can ask you what things you didn’t like about it. If you’re able to give me concrete answers, I can avoid those things.

If I end up believing that some part of CBT really would make an impact, even if it annoys you, I can convey that! “I know you didn’t like getting homework because it felt childish, but I think I could help you much more if I had a sense of what triggers your anxiety at home, and I wouldn’t be surprised if you learned something about yourself too. Would you be willing to do a trial period of documenting your panic day to day?”**

Even better, you’re getting information that lets you self-advocate in future therapy settings. If your first therapist tells you they were CBT-focused, and I tell you that I’m mainly doing narrative therapy, you get to convey what worked and what didn’t to any future mental health professionals. If you end up needing some immediate help, or can’t afford an appointment, you’ve got a starting point for googling. You’ll know that Feeling Good is less likely to work for you than Retelling Our Stories, because you can read the flyleaf and compare it to your experiences.

But perhaps most importantly, giving clients information about a treatment plan or orientation can prevent them from generalizing one therapeutic orientation to the profession at large. A client knows that you’re doing one thing under the umbrella of therapy. It’s much easier to say to a therapist “this specific thing seems to fail” than “I think the thing that is your profession (therapy) doesn’t work for me”

*I recognize that sometimes telling certain clients (for instance) that you’re trying solution-focused brief therapy is going to derail the crisis work you’re doing, or going to paint you as an ivory tower academic who doesn’t understand.

**For the curious, this is the worksheet I was thinking of.

Room in Recovery

Related: A Week

[Content Note: Discussion of eating disorders, some of which might make recovery harder. I don’t actually endorse the feelings here as ones I want to have.] 

I remember when I first started following other people writing about eating disorders how shocked I was that they prided themselves on not being in recovery. They seemed to not want to hit ‘recovered’, and I could not understand. I thought of recovered as necessarily good, a picture in my head of resetting the clock and going back to ‘normal’. And oh god, did I want ‘normal’.

I had friends who had recovered from OCD, depression, anxiety. Their lives were unquestionably better for it. Even a little bit of recovering, a little bit less depression, anxiety that wasn’t quite so debilitating, was wonderful. I wanted that. I expected that.

But I don’t think that’s what most of us get, recovering from an eating disorder. Of course, there’s little things: having more energy, fewer dark circles under my eyes. Less distress at the prospect of picking out clothes in the morning. But on the whole? Eating enough food means beating back the brain demons that think it makes me repulsive, horrible. It means spending willpower to remember that yes, you will eat lunch today. It means deciding to be more stressed and less happy because I’ve forced some bit of myself to remember that depriving isn’t good for me.

This isn’t part of the recovery narrative you hear, right? The part where you decide to pick “less happy, more healthy” over and over?

I want there to be space for hating recovery. For clawing at it with your fingernails, for wishing you hadn’t, for being less happy as a result. For putting on a brave smile to encourage others because it’s wrong (even as it’s also right) to say aloud that sometimes the only way you tolerate recovery is by viewing it as a challenge that will make others happy. And you love challenges.

I want there to be space to discuss the hard questions. The ones that sound like “If I eat, I’ll be too anxious about it to study for this exam. Which matters more?” and “Do I tell him that the things he likes about my body are the same things that make me cry?”

Recovery can look like this too.