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.

Monday Miscellany: Hamilton, Havens, Harm Reduction

It’s 2016! Time for the yearly commitment to blogging more.
1. Hamilton is an under-appreciated genius. No, not that one, this one.

2. Institutionalization and the burrito test.

3. Relatedly, a photographic memoir of Rockhaven, a kinder kind of institution.

4. How successful is inpatient treatment for the mental experience of anorexia? Not very.
[Note: whether or not inpatient treatment makes people less anorexic is different from whether or not it forces them to gain weight.]

No significant changes in core anorexic thoughts and perceptions as Body dissatisfaction, Drive for thinness, Weight concern and Shape concern were noted. However, a reduction in the general severity of eating disorder symptoms (including Restraint and Eating concern) was observed, mainly related to the treatment structure. Levels of depression significantly decreased but remained within pathological range. We also found a concerning increase in suicidal ideation not correlated with a concomitant increase in depressive symptomatology.

I suspect that the increase in suicidality is related to being frequently (usually daily) weighed, and that some of the other effects come from being cooped up with a bunch of other people with anorexia and feeling competitive.

5. This sounds a bit like throwing the baby out with the bathwater: psychologists are being removed from Guantanamo:

The new rules bar psychologists from any involvement in national security interrogations, and also bar them from providing mental health services to detainees at sites like Guantánamo that the United Nations has determined do not comply with international human rights law. Currently, no interrogations take place at Guantánamo, Commander Burzynski said, and instead only voluntary interviews are conducted when a detainee asks to speak with American personnel.

As a result of General Kelly’s order, psychologists at Guantánamo no longer observe or are involved with detainee interviews, or provide any feedback to the American military on detainee behavior, according to Commander Burzynski.

The psychologists have also been removed from the prison’s Behavioral Health Unit, which is responsible for detainee mental health programs, and from the prison’s so-called detainee socialization programs.

6. Alliterative author ambles through actions around Oregon shooter language in reporting. 
7. Transitions vs. turning points; an interesting framing for life changes. 

Monday Miscellany: Tickling, Thoreau, Telegraph Chain Mail

1. People with schizophrenia probably can’t tickle themselves, and this explains hallucinations. Maybe. (I asked some friends with schizophrenia and got one “I don’t think this is true” and one “this is true, but only when I’m having an acute episode”)

2. Ben Orlin illustrates probability, as interpreted in various professions.

3. Motivational Interviewing is one kind of therapeutic technique, best used with clients who are unsure they actually want to change. (For instance, people who have an alcohol problem, but aren’t willing to endorse that it’s a concern.). I find it fun and interesting, and this training lets you choose-your-own-adventure while being rated on a variety of good-at-therapy skills. (No need to register, you can launch the session without).

4. The author takes the position that Thoreau should be dismissed as a raging hypocrite, I take the position that he sounds like a person caught up in scrupulosity obsessions.

Relatedly, I recommend Devil in the Details as a memoir of obsessions.

5. “What else could we have discovered if we hadn’t been striving for a ‘normal’ we’d never reach?” Disability camps.

6. I was curious about the origin of chain emails, and the story was better than I could have imagined. Involves Jack the Ripper, Pulitzer, telegraphs.

The “peripatetic contribution box” was seized upon in Britain as a weapon against, of all people, Jack the Ripper. That November, the Bishop of Bedford oversaw a “snowball collection” to fund the Home for Destitute Women in Whitechapel, where crimes against prostitutes were raising an outcry for charitable relief. The Bishop’s snowball worked: Indeed, it worked diabolically well. It snowballed, so that along with 16,000 correctly addressed letters a week burying the hapless originator, garbled variants of the return address also piled upon the Bishop of Bangor—as well as Bradford and Brighton.

Doing/Trying Diversity

The thing, or at least, one of the things about moving a movement or an organization towards greater diversity is that it involves tradeoffs, especially initially. You are changing your current way of doing things—this is not simple.

I mean, sometimes it is, right? You make it easier to find your maternity policy, or you use gender neutral language in your application, or you stop having all your off-work events in bars. But sometimes it means writing your maternity-leave policy, or changing your working hours schedule, or having really awkward conversations over and over and over with your current employees.

I think that it is sometimes okay to decide, yes, we want this change eventually, it is important to us, but right now the tradeoff seems so costly that we cannot do it.

But decisionmakers—sincere ones!—can lose the benefit of the doubt when their public calls about the need for diversity are paired with private decisions that the tradeoffs in this case (and this one and this one) are too high.

Wanting to have a diverse organization is easy. Actually doing it is hard.

Some examples:
1) Organization Alpha works with families near the poverty line. They would really like to hire more people on the frontlines who have been there—men and women who are living pay-check to pay-check, for instance. They frequently hold career fairs during working hours, because they don’t want their current employees to have to work overtime or arrange for extra childcare.

2) Non-profit Bravo works with a predominantly-male population. However, they’re seeing a disproportionately small number of women, even taking this into account. They’d like to have more employees who are women. They do not currently have a maternity leave policy—women must accrue sick days or leave.

3) Conference Charlie is concerned about the growth of [the field]—fewer and fewer young people are getting involved. They would like to increase involvement of students, by inviting them to a three day conference full of people who are enthusiastic and dynamic speakers. The conference takes place in a city that is small, but has many [field] enthusiasts. Student tickets are half price, at $300.


[Content note: rape, sexual assault exams, almost nothing else. ]
The organization I volunteer for is excellent and highly recommended. However, statements below should be taken as from me, not from them.

To the best of my knowledge, I’ve specified where I know that there is state-to-state variation and I’m speaking for Massachusetts

On the good days it looks like this:

I get a call from the woman supervising my shift. She’s on the same line as the SANE nurses who administer the rape kits. When they get paged to go to a hospital, we do too.
I pick up my bag (pamphlets, a binder of resources, phone chargers, fidgets, notebook, pen), head to whichever hospital called in.
The SANE and I arrive at nearly the same time—she isn’t tied up on another case.
The client is in a private room with a door that closes.
The nurses have been kind to the survivor.
Someone has told them what’s going on, who will be arriving.
We spend four hours or less going through the kit.
The client is alone or with someone who cares for them, who thinks this is worth doing and they are brave for doing it.
They have a place to go home to afterwards.
They have eaten that day.

Not all days are good days.

In Massachusetts, you do not need to have reported your rape/assault to the police to have evidence collected. This is not the case in all states, and not the case in adjoining states, necessitating that we ask survivors where their residence is located.

Some reasons I think the MA model is superior: it allows people in abusive situations to go into the hospital, document evidence of a rape, and then after leaving the abusive situation, involve the police. If you’re in fear for your life, or the lives of loved ones, this can be safer.

Rape kits, which are technically known as sexual assault evidence collection kits, are identical for everyone 12 and up—that is, they contain the same (in MA) sixteen steps of evidence collection.

Importantly, (in MA) anyone of any age can decline any step. A twelve year old can say they would prefer not to have any oral swabs taken and that’s that. Informed consent is gathered from the survivor, not the parent, in all cases over the age of 12. (I’m specifying there because I don’t interact with under-12s, and don’t know how it works).

I expected to find the children the hardest, but this has been surprisingly untrue. People—nurses, doctors, technicians have been around children. They often have children at home, or in their extended family. There are very few* circumstances in which these people can be persuaded that children deserved to be assaulted or aren’t interested in being helped.

This is not usually how people—nurses, doctors, technicians—feel about people who are homeless, or people who have abused drugs, especially if those people have been in the emergency room before.

The last time I walked home from a hospital after a case, I got catcalled. This happens maybe a third of the time—it’s usually late, I’m usually dressed up, the hospitals are downtown. This doesn’t make me feel better about the state of the world.

Home. I smell of hospital. All my clothes—no exceptions—go in the wash. Hot shower. Scrub. Soft clothes. I call in to the woman who sent my out, my supervisor. I talk her through the case—where I was, where the assault took place, how many assailants, what kind of assault, was the client safe, how did I feel, what staff were involved, how did they treat the client. I say the things, the details I don’t want my partner, my friends to have in their head. Sometimes I tell the same story twice, three times, repeating ’til the initial horror and revulsion has bled out.

I am pretty sure if you can’t forget the stories, you can’t live with this job. I do not remember the names, and this is a conscious choice. I call in the referrals (counseling, legal, case assistance) and put a penny in a jar and go back to my life: a party, a book, sleep, people who have never left bruises on my wrists, face, legs.

There are too many pennies.

This is a good summary of the steps of a rape kit.

*Sadly, exceptions in the case of teens who went to parties.

Monday Miscellany: Blimps, Boundaries, Bodily Experiences

1. Did you know you can see footage of a glacier from 1937? Did you know you can see footage of a glacier from 1937 filmed from The Hindenburg?  (Yes, that one). h/t Jeff Wagg

2. This article in The Atlantic begins as West Point Professor Who Contemplated a Coup and goes pretty immediately to cloacas, which are helpfully defined as a kind of animal orifice.

3. Lovely Miri is writing at Everyday Feminism with an article on setting boundaries with your therapist.

4. Two religions are having marriage crises, with two single women for every single man.

5. Stephanie rounds up writing on improving the ‘diversity panel’ at conferences.

6. California reduces its use of solitary confinement. More on the use of solitary confinement across the U.S. here.

7. Romantic chess.

8. How does anorexia impact the internal experience of being in your body?


Source: Art of  Seamus Gallagher
Source: Art of
Seamus Gallagher

The bystander effect is really terrifying.

I got followed (loudly, publicly) today, by two men.

This isn’t the first time it’s happened, or the first time a large number of strangers in ear- and eyeshot declined to do anything. It was also very obvious: two men were shouting, making gestures, and pointing at me for an entire block in a crowded area.

I had headphones in, was not walking with them, and well, I don’t think most people’s conversational style with people they don’t know is “walk in front of them, at increasing speeds, while they shout and point”.

…I also don’t think most people know what to do when they see this happening. I hardly expect 15 or so people in the vicinity approved—several were women my age. To that end, here are some things that might have helped me either feel less trapped or bring the catcalling and following to end.

  1. Making eye contact at all. Highly recommended! I don’t live in NYC, and it’s not unusual for people in my part of town to make eye contact or smile as they walk by others. But as soon as there, ah, began to be a public discourse on my body and attitude, the people passing me wouldn’t make eye contact. This felt especially lonely and scary. A sympathy!face or eyeroll can make me feel as though there are people on my side. (This isn’t something I usually feel I can assume; I’ve also been lectured by strangers for being unfriendly when I told people catcalling me to leave me alone). When everyone goes to immediately pretending I don’t exist, it sends the signal that I’m doing something embarrassing or making a faux pas.
  2. Pretending as though you know me, and immediately starting a loud conversation. (Almost entirely directed at women/not-men, as it would take me a second longer to determine if another man was pretending to know me to be helpful, or part of the set of men catcalling me. I’m usually using a lot of my focus on staying calm.)
    “Hello Susie! Long time no see! How is work going for you?”
    [begins walking alongside the person]
    [chatter loudly until catcalling/unwanted conversation from catcaller stops. When I’ve done this it felt like it took about 30 seconds, but was probably more like 10 or less.]
    “Hey, sorry for being so strange, I just figured you wanted to not deal with the catcalling.”
  3. Depending on the level of escalation happening, loudly and obviously saying that you’re calling the police, etc.
    This instance wasn’t particularly severe (a previous one involved an enclosed space and someone yelling loudly and getting very, very close + giving signs that he might escalate to violence), but one available option is pulling out a phone and saying loudly “I AM CALLING THE POLICE NOW.”
    Downsides: you might not want to direct all attention towards yourself, which is a valid concern.

It seems possible there are things that people could say directly to the catcallers that wouldn’t escalate the situation, but I’ve never seen this happen, and I’m nervous to make suggestions that might backfire.