IAmA licensed therapist who writes about and specializes in working clinically with severe anxiety, clients who play video games, e-sports athletes, & couples. I'm passionate about de-stigmatizing therapy and breaking down barriers to seeking ...

What are the best ways to treat anxiety? And if someone has gotten to the point where they find it hard to leave the house or be around people they don't know really well?

If you have the means, finding a therapist who is willing to see you remotely could be helpful (video sessions) so that you don't have to leave the house at first could be really helpful. It may also mitigate some of the social anxiety being experienced since you don't actually have to go into an office with a stranger.

That said, the support of somebody who can help you alter the way you converse with your own anxiety is a HUGE first step. Anxiety is a very hard thing to tackle alone, especially when it is severe.

A big piece of my work is helping people see the purpose of the anxiety and then see themselves as having agency to act in the presence of anxiety rather than waiting for it to go away.

Do you or anybody else know a good place to window shop? Or do you just do this via locality?

Edit: Just realized how silly the locality question was given the context.

Psychology Today is by far the best place to window shop. You can see what's out there and even filter your searches. In case you're wondering, they don't sponsor me. I just like the service a lot.

Dr. Mick! Hello! I was super excited on your first AMA to see the combining of video games and therapy on Twitch.

Now that you have been streaming for nearly a year, what has been the most unexpected, rewarding and difficult parts of your streaming experience thus far?

Thank you for the AMA and for streaming!

Unexpected - the amount of support and outreach the stream has had.

Rewarding - see above, plus the fact that so many people have told me that the steam/community have literally changed their lives or helped them become more comfortable with the idea of seeking therapy

Difficult - staying on top of all the tech that's involved and making sure that I'm very clear within disclaimers that I am not doing therapy on stream

Thanks for your support :)

This answer is coconut man approved!

If I could further ask about your motto:

"You matter. Your experiences are valid. Don't let anyone tell you otherwise."

I am curious, if your therapy clients/patients know your motto or if it is posted in your office at all.

Thanks again!

No, actually. It's stream-specific. I have DEFINITELY said those three statements (maybe not all at once) many times over the course of my 7 years as a therapist, though.

Hi Dr Mick, I've been considering finding a therapist but it seems pretty overwhelming. I want to make sure I find the right fit. What is the best way to do this? Are there things I should be on the lookout for?

Great question! It's actually common for people to get cold feet when they first call a therapist - but make sure the vibe is right. It's ALL about relationship if you don't feel comfortable on the phone or in the initial consult, go somewhere else. You are under NO obligation to see a therapist just because you called them.

Be weary of any therapist that tries to "sell you" on their services.

There's been a lot of talk blaming video games for alt-right radicalization... but I'd like to pose an alternate hypothesis and get your opinion on it. What if video games themselves aren't doing anything, but what if the associated communication channels are? Things like discord, teamspeak, any VoIP, chats, YouTube, twitch... any media platform that could be used to host alt-right messaging, and target disaffected or struggling folks. It doesn't have to work on everyone, or even a majority. I've also noticed a change in gaming culture, it seems like it used to be like sports, kind of taboo to get overly political. But somehow somewhere between a decade ago and now, it seems that taboo is totally gone. Aliases, match names, VoIP filled with the stuff. What would you think of this concept, not the games, but at times some of the comms and media around them?

I tend to be in agreement with you, and this is an awesome observation. The human interaction part of games is by far the part that has the most influence on people. So yes, more channels for various streams of information, values, etc. make it more accessible to others, including people who are vulnerable or impressionable. And people have the ability to choose which flow of information to consume, which can play to confirmation bias in due time.

Participating in your streams and Discord has help me have better conversations with my therapist over my care. What would you advise someone in therapy to get better sessions from their therapist?

Tell your therapist if you aren't happy with your therapy! YOU are the consumer/customer, so your therapist should be wiling to make adjustments if needed. If the relationship just doesn't work, ask the therapist for referrals (they are ethically have to provide you with them if you ask).

Don't ever feel like you have to force it with a therapist. Shop around!

Last week I finally got the courage to tell my therapist that I didn’t want to live. She completely glossed over it and ended the session 5 minutes later with no safety check and offered me cake in the break room (I have an active ED, it was a bizarre offer IMO). I was admittedly hurt by her reaction(s). How do I approach her about this in our next session? For 2 years she was the greatest T I ever had but she’s been distracted and self-absorbed lately. I’ve been just sucking it up, but since you’re doing this I thought I’d ask.

First of all, I am grateful for your willingness to be open about that experience. I'm sorry that that happened to you.

Honestly, if you feel comfortable, I would recommend talking to your therapist and laying your experience out there. If a therapist ever gets defensive when a client shares their experience of the therapy, that is generally not a good sign, and I often recommend the client seek referral or another therapist. At the end of the day, clients are the customers/consumers, and should be in a context where they feel heard and validated.

My hope would be that your therapist could hear your concerns/experience, and engage in meaningful dialogue with you. Because your experience of the therapy is SUPER important, and the alliance between therapist and client is what contributes most to whether therapy will or will not be effective.

If you don't feel comfortable sharing that with your therapist, I might recommend finding another if you are able/ willing.

Hi DrMick! I’m stuck at work but wish I could hang out on stream right now.

A few questions:

1. What inspired you to start streaming? Was there a particular event that brought it about?
2. What is your favorite mental health topic or fun fact that you’d like to tell people about?
3. What is your favorite gaming experience you’ve had?

1. I wanted to give gamers (and non-gamers) access to mental health resources and information from a person who is licensed and credentialed in a way that they could relate to using a service that is comfortable to them (Twitch)
2. I love talking about learning (how we learn, what it entails, etc.) and anxiety management. I also enjoy talking about the affect technology and video games has on who we are and what skills we develop!
3. The first time my raid group cleared the Kings Fall raid in Destiny 1. I don't think I'll ever top that feeling in a game.

How would you recommend getting a loved one to seek professional help for mental health, especially if initial attempts fail? Any resources on the topic you'd recommend?

At the end of the day, unless you're a parent responsible for a minor, you cannot "force" a person into therapy. However, I encourage everyone experiencing this issue to take time to listen to the potential shame and vulnerability around the suggestion. Suggesting therapy to a person often brings these feelings up, and they are worthy of listening to. Be supportive, warm, and compassionate, and hear their concerns. That might invite a more effective conversation :)

Also, help the person search for therapists and be a part of the process so that they don't feel alone - that can go a long, long way!

With the recent events that have happened in Texas and Ohio, do you feel like mental health is being used as a scapegoat? As someone who has suffered with mental health problems, I feel like it is adding to the stigma that we are trying to get rid of. Do you think that these people that have done terrible things could have been prevented with proper mental health screening? Or do you feel like it is a cop-out excuse?

I think it's complicated. Mental issues can certainly play a part, and I don't want to say "mental health has nothing to do with it". That said, I think a lack of access to therapists and mental health services is contributing to the problem. If we are going to say it is a mental health issue, we need lawmakers to put their money where their mouth is and make mental health treatment accessible to everyone as a preventative measure.

It's a complex system of gun laws, mental health access, stigma, discourse, media representation, and more, which is why it seems like so many people come at these tragedies from so many different directions.

I wish, as a therapist, that I could be able to see more people and that more people struggling with their mental health had insurance that would give them access to therapists in their area. I also think state licensing is quite restrictive because it means therapists cant have a national clientele.

How did you first know you wanted to be a therapist? And how did you first get into gaming?

I've been a gamer all my life. Got a SEGA Genesis on my 5th birthday and I never looked back!

I got into therapy because I was always the guy that people turned to when they needed somebody to listen to them. I figured I could make a living off of my fascination with relationships and how they are configured. Now I combine the video gaming with it and it's awesome!

First game you got for the Genisis?

Sonic the Hedgehog 2

Tails or Sonic?

When I was a kid, it was always Tails. I loved being able to fly around, and I always felt bad that he would die so much when I played as Sonic.

As an adult, though, it's Sonic. I just turn Tails off and give him a rest for all the trauma I caused him back in the day.

Why did you decide to become a therapist, and what made you choose this topic as your focus?

I became a therapist because I absolutely LOVE relationships. Why people partner with who they do, how they navigate them, etc. It's like a puzzle every day when I go to work and it's awesome. I also get to learn various aspects of what it's like to be human that I wouldn't otherwise get to learn since I can't engage in the entirety of human experience as one individual - if that makes sense

What is something helpful or beneficial about therapy you want more people to know about?

SO many things. First, I want people to know that MOST therapists are out there because they genuinely care and want to help. Therapists who are out there "just for the money" or "take advantage of people's suffering" are a very, very small minority.

Therapy is a chance to explore whatever you want to explore with a person whose job it is to sit there for 50 minutes and fully tune-in to what you are expressing/ what you care about. And you don't have to worry about that person passing judgment or operating from their own agenda. (If they do, you should consider another therapist).

It doesn't have to be super intense all the time - it can actually be fun to have somebody to check in with every week that you don't have to worry about talking with at any other time. We hold all of your anxieties, issues, etc. and allow you to revisit them at your own pace.

So many more things but I'll keep it at that for now :)

I remember your previous post! Have you received any critical or negative feedback from other therapists on stream? Or maybe have you had someone off stream tell you they disagreed with something you said?

No, actually. And I mean that. People have been incredibly supportive of it, and I've had several people (therapists/mental health workers) reach out to me to ask how they could start doing it themselves.

As far as disagreements - they happen. But I'm open about the perspectives I have when answering questions. I'm always willing to learn from others if I might be wrong about something, though.

Hi DrMick

I'm currently going through a rough patch in my family. One of the topics being argued about is video games. My wife thinks I'm addicted, whereas I am not. I know that this might not be the best place to inquire, but to be honest, I just need a little bit of insight.

So I don't get much time to game. Given the family situation, work, etc, I get "me" nights two days of the week, in which I have two hours. I usually take advantage of these two hours. Other times if my wife isn't feeling well, and has me sleep in a separate room, I'll stay up few hours and game. Other than that, I don't get much of a chance to. I've maintained a job for 20 years, and I keep up with my responsibilities. Gaming has been a hobby/passion of mine, and I'd be unhappy to not be able to, but I'm feeling resentment over the fact that I'm being called out on something I don't see as a problem.

I don't know what I'm getting at, and I know the information I've presented is limited, but do you have any thoughts on what I've commented?

First of all, I think open, honest, and direct communication is the way to go in a marriage or intimate relationship. If it seems too scary to do that without help, a couple and family therapist could be very helpful in helping that conversation along.

I think it's important for non-gamers to realize the role gaming has in our lives so that they can realize what it is they are not understanding or mis-understanding. I've found that when people can be open about what video games mean to them, and they are in in a healthy relationship, that conversation can open up a lot of dialogue about how to include video games within the life of the couple/ individuals involved.

Best of luck to you!

What’s the best way to approach someone if you think they are depressed/suicidal?

Name it and ask, but be ready to listen to them if they confirm your suspicions. Acknowledge the reasons they want to die or are depressed. If there is immediate danger, encourage the person to go to an emergency room (or take them yourself) or call 911. Crisis lines (including the national suicide prevention lifeline) are always available 24/7 (in the US) even if a person isn't actively suicidal (the phone operator will still listen). Also recognize your limited responsibility to help them through it and encourage a therapist if they have the means.

The worst thing you can say to somebody who is suicidal is "you don't want to do that" (invalidating) or to a depressed person is "well do something that makes you happy then". Invalidation makes things worse. Acknowledgement and validation is key (as is having the person be proximal to others rather than isolated).

I know that there are some who would argue that media like certain video games leads to greater stress, anxiety, and anger, and others the exact opposite - that these games provide a healthy outlet for emotions that might lead to such problems. Based on your description, I would guess that you probably lean toward the latter. However, do you think there are certain games that provide a better release for stress and repressed emotion, and that some should be avoided? Additionally, do multiplayer games show any appreciable difference in the effect, either positively or negatively?

I love this question. Yes, I fall toward the latter, but I do acknowledge that gaming can have adverse effects on people if they aren't conscious about the effect its having on them. I think any type of game can have positive affects on a person, but I've the most positive effects from games that facilitate coordination, leadership, accountability, and socialization. So, MMO's, looter shooters, stuff like that. That's mostly anecdotal though.

Multiplayer games are a mixed bag because of anonymity. That said, if a person is careful about what social circles they run in while online, it can be an amazing experience. MANY transferable skills can be learned from video games and pulled into the real world (problem-solving, leadership, LFGing, etc.)

It depends on how supported a person is in their IRL systems with video games as well. That's why I think people need to be more aware that there is WAY more that goes into video games than "I'm just having fun"

I’m sitting in the waiting room of my new therapist as we speak. I have crippling anxiety and this is like a sign to me that it’s going to be okay. I’m glad I took the first step and I’m glad you’re here doing this for everyone.

What advice do you have for people taking the step and starting out in therapy to keep up with it and not lose motivation to get better?

You deserve SO much credit for taking that step. It's admirable. And I appreciate you sharing that with me. I hope the experience is helpful and fulfilling for you :)

My advice to anyone in the situation you describe would be to not put too much pressure on yourself to change too quickly or to "get better". Be patient with yourself. Therapy can be awesome but it can also be hard, and the more self-compassion and patience you can have for yourself will make the process easier to take on. Acknowledge where you are before pushing to where you want to be.

Also, if you start to get burned out or if it feels like therapy isn't helpful, talk to your therapist about it if you feel comfortable enough to do so! It's YOUR time after all.

Best of luck to you - I admire your willingness to take the step, especially if anxiety makes that difficult to do.

Hey DrMick. It's great to see you back on Reddit for an AmA.

My question is this: When it comes to therapy for teenagers and young adults who are there because of someone in an authority position (parents, guardian, court order, etc) how do you make the experience not only worthwhile for them. But also make it to where you're time with them isn't just a massive headache?

Also which Halo is the best?

Mandated therapy for teenagers can be tough, but doesn't have to be. A big part of it is really exploring what the motives for the teenager are, and not "forcing" therapy on them, per se. So, for example, often a reluctant teenager might agree with the statement "I'd like to not have to come here anymore" in which case the therapist might respond by saying "well then lets figure out what you need to do in order to make that happen". So in that case, the teenager might comply or set goals as a a means to not have to be there.

In my experience, connecting with their desire to not be there, can be a huge source of empathy and relationship building.

It's very important to establish boundaries with parents as well, as best you can, so that the teenager doesn't feel like they are constantly under a microscope. I always say I will report emergencies and risk items, but beyond that, I try to hold a confidential space, and I will tell parents that encroaching on that confidentiality might destroy my relationship with the teenager.

What is your best non-professional advice for compassion fatigue? I'm a nurse and people say "take time off" etc, but most people cannot afford to do so. I know I am good at what I do but I am feeling worn down.

I think I am in a funk and I really cannot afford therapy right now.

Compassion fatigue is very real. If unable to take time off, I think it's important for a person to acknowledge that it's happening and sort of "own it" rather than trying to act as if it isn't there. Self-validating and finding compassion for the experience and then making an effort to decide how to navigate work, life, etc the way they want or need to, maybe with some extra boundaries where possible, despite feeling tired or burnt out.

Invalidation or ignorance of compassion fatigue, in my experience, just makes it worse.

Then, when the time does come to be able to take some time off, really make an effort to immerse yourself in the time off. Time off doesn't work if we continue to ruminate about work during it.

Hello, sir! Fellow counselor here. Just wanted to tell you to keep up the good work. Any tips for getting started and engaging with clients in this context?

Thanks!

Which context do you mean?

Over Twitch or electronic media (confession: I've been working on a podcast concept to talk about everyday mental health topics)

Shoot me a DM. I'll be happy to talk to you about it!

Hey Dr. Mick. Recently discovered your channel and love your content. Keep up the great work!

My Question:

What is an under served and/or under represented aspect of psychology/therapy that you think should get more attention or resources and why?

This question rocks.

I think therapy itself is not represented well. Right now, when people think about therapy and haven't had exposure to it, they tend to bring up something like Dr. Phil, which is not at all an accurate representation of the therapy process. Like, not even close.

I think people should see how warm the process be, that it isn't something that has to be rushed, and that it truly is a special form of relationship that can help you achieve personal and interpersonal goals.

I wish more people could see what therapy actually looks like so that they wouldn't be so afraid. I also think having MORE representation would be helpful so that therapy becomes more "out there" and acceptable to engage in without worrying that others will stigmatize or isolate them as a result of going.

:) Right on, thank you!

In respect to representation, that leads me to something else I've been thinking about. What are your thoughts on minorities (PoC, Hispanics, native populations, etc) with respect to therapy? I'm thinking in terms of inclusion on the profession side, and representation as clients. What has your experience been like with minorities, if you have any?

It's a very complex issue with a lot of moving parts. First, I think we need more representation of marginalized/ minority groups as therapists so that people have access to therapists who look like them/ have similar values/ similar inherent lived experience, etc.

I also think that marginalized groups need more access to mental health services. Because of the way institutional oppression works, marginalized groups often don't have access. No access + no representation = limited desire to seek services, or the therapist does not share similar characteristics. Does that mean a therapist who isn't part of the same group would be bad? No. But representation is very important.

My experience working with minority clients has been awesome. At the same time, I work in an area (Chicago) that has diverse representation within therapists, so people have more options to find what they think will be best.

Right now, therapy access is generally a privilege, but I think it needs to be more accessible to everyone, and that starts at the level of policy.

Hey hey! Look who I found while scrolling on the front page of reddit!

Anyways, to actually contribute to the AMA with a question.

What do you generally recommend/try to teach/speak about with patients who have recently come to learn or be aware of the fact that their family/childhood was rather dysfunctional and thus their relationships in general have been suffering because of it? Subsequently, how do people better learn more about what healthy relationships with family, friends, SOs, etc. look like?

Ha! Good to see you dude! And awesome question.

A big part of is is learning which messages we carry from our family of origin, and being able to differentiate which narratives in our head our "ours" versus our "family's". For example, if a person keeps saying "I'm worthless" it may be that that's what their FAMILY wants them to think, but it isn't what they actually believe. Separating those two things can be super helpful.

Also realizing that in adulthood we don't owe our family of origins anything, especially if they were destructive. Setting boundaries can be very helpful, as can validating the reasons why those boundaries are being set. It's very easy for us to carry our family's narratives and get wrapped up in them, so it's important to connect with our own desires so that we can effectively manage those relationships going forward.

Your last question is also interesting - sometimes it's a matter of teaching people what they look like and helping them identify relationships in their lives that fit that mold. And then working with the anxiety of engaging in those relationships, because believe it or not, healthy relationships can cause anxiety for people who always had unhealthy ones since they are new and unknown. It's something people don't think about, but is definitely worth putting out there.

What are some major red flags when looking for therapists and inversely, any signs that might show a therapist is particularly good?

GREAT question!

Red flags: trying to "sell you" on their services, operating from their own agenda rather than from the clients', passing judgment overtly on to the client in a way that is harmful, being aloof in sessions, forgetting important items, "rushing" the process

Green: Openly discuss the importance of building a relationship with clients, making non-judgmental observations, holding clients in positive regard but also holding them accountable to their goals, and BEING OPEN TO FEEDBACK from clients (that one is huge).

If you feel good vibes/ like it's a good match, that's a great sign. If you feel at odds with yourself when in the presence of a therapist, that's generally not good.

How can someone with no health insurance, or someone with poor coverage, get access to affordable therapy?

Pasted from another answer:

This makes me sad that so many people have to ask this question. I wish there were policies in place to make therapy more accessible to people.

That said, there may be a few options. First - many therapists (including me) will keep a pro bono client and/or sliding scale client on their caseload. Pro bono means no cost, and sliding scale means what a person can afford. Most therapists don't advertise it though. It never hurts to ask if you do some searching and find somebody who looks like they'd be a good fit. If you have a university in your area with a clinical program, there's a good chance that students are seeing clients a low or no cost. And research shows that therapeutic outcomes between students and seasoned therapists generally aren't that different.

Finally, sites like adaa.org have affordable therapy finders.

If all else fails, local crisis lines are free and can be used to talk stuff out. I worked on one for three years and you don't have to be in dire straits to call. The person on the other end is trained to listen and help with problem solving. While not a therapist, it can be better than nothing.

Lemme link you to a comment I just posted that was for a similar question. I hope that can help you in the meantime while the Doc tries to keep track of questions!

Thank you!

You said you specialize in couples therapy as well, what’s something a lot of couples ought to know but don’t?

That validation of the other person's emotional experience, no matter what it is, pays off in the long run. You can hold your partner accountable to their behavior while still acknowledging how they feel. I know that sounds cliche, but it's pretty amazing how hard that can be, because many people conflate validation with "losing" or worry the validation won't be reciprocated.

It's harder said than done, but can become almost automatic with conscious practice.

I also think it's important to understand that when a person is emotionally flooded, their brain quite literally cannot process data input, so it's not useful to keep trying to make rational arguments or pile on until the person calms down.

Can you describe an "Ah-Ha!" moment you had with a client, whether it be on your client's side or yours?

Regards,

The Great Patsby

I can't give a specific example (to protect confidentiality), but a big Aha moment that happens frequently due to the nature of my work, is when people realize what happens when they change their relationship with their emotional experience to one of a "partnership" that includes curiosity, patience, and warmth after having an adversarial relationship with their emotional experience for a long time.

It's amazing what can happen when people have language for how to interact with their anxiety from a compassionate place. If we give ourselves some space to validate our own experiences, it's a wonderful thing. When people realize that, it's always an amazing moment!

Hi Ryan! I’m late to the game here, but how did you decide on MFT over counseling or social work? I’m an undergrad senior in psych and want to be a therapist, but there are so many options out there it’s hard to pick one - and my own anxiety doesn’t help!

I knew I wanted to work with relationships. MFTs are trained to do that. I'm also drawn to a systemic view of the world rather than an individualistic one, and MFTs share that value.

In trying to decide, think about the types of clients you want to work with, and in what setting. If the answer is relationships, MFT is a good way to go. If the answer is policy and large systems and case management, social work would be the option. If you want to do some deep psychology, psychological assessment, diagnostic work, and individual work, clinical psychology may be the option. If you want to work with meds and severe psychosis, psychiatry is it.

That's really what it comes down to. I think an MFT degree is the most versatile, but I'm also biased. You can still work with individuals, but you have a systemic view to take in your work, which I think is necessary.

Best of luck to you! If you have any follow up questions about the process, feel free to DM me. I like helping people sort that stuff out.

Good morning, Dr. Mick! I realize that you are no longer actively live in this AMA, but hopefully you will see my question and be able to respond to it at some point in the future.

My questions are about OCD.

The primary treatments for OCD — CBT, exposure and response prevention, and SSRIs — are effective for many OCD patients. However, even if treatment improves the sufferer's quality of life, OCD symptoms remain, and relapse is common. Additionally, some symptoms of OCD, such as counting behaviors, are more difficult to treat using the "traditional" first-line options.

How effective are the primary OCD treatments, in your experience? Is it a dart-throwing game to get results, do we need more research, or has the right answer not been found yet? What would some fall-back treatment options be for a patient for whom the first-line options have failed?

Finally, if you had the opportunity to advise the patient's spouse, family, or other advocates: How would you help them better understand the mental impact of OCD? What support can they give to someone struggling with OCD, and how can they help with treatment and recovery?

Thank you so much for devoting your time and headspace to this AMA!

Haha had to sleep a bit. Woke up to a deluge of questions so I'm making the rounds trying to get to as many as possible!

OCD is tricky and complicated. I use an integrative approach when working with OCD that's tailored a bit toward the relative manifestation of it for a given client. That said, I've found cognitive restructuring, ERP, and honestly some emotionally-focused work to be very helpful. Really getting into the emotional experience of OCD can open up a lot of avenues to move forward with treatment. It's often couched within intense fear and anxiety that gets misplaced - and then the emotional experience takes over and a control fallacy develops. Sometimes it's "I don't have ANY control" and other times it's "I have ALL of the control". Both aren't true.

So, in simple terms it's: identify the emotional experience -> validate it -> acknowledge the intrusive thoughts and urge to engage in the compulsive behavior -> build distress tolerance by sitting in the discomfort and then making a decision about how to proceed -> selectively focusing on objective data -> reinforcing the consequence of acting differently rather than out of impulse -> and so on. This has other steps added in depending on the situation.

Meds can help, but I have quite a bit of success working with OCD where meds weren't involved at all. I will make a referral to a psychiatrist or GP if needed though.

To answer your last question - understand and really realize that it is DEBILITATING to have OCD/ intense intrusive thoughts. It's no joke, and it's utterly miserable. Saying things like "it's not a big deal" or "come on you're not being rational", while maybe true, are very invalidating to the person's experience. I actually recommend family members join therapy for a session or two to learn about the person's OCD and how to respond. It also helps the system know what's being restructured so they can adapt accordingly. And, finally, be patient with the person. OCD sucks a lot and is hard to work through. Patience is a godsend.

I have been seeing my therapist once a month for about 9 months. Usually, I talk the entire time nonstop. Our last meeting, though, the words dried up after 20 minutes and I wonder how you deal with this kind of thing? I’m not sure if I need to talk less or if I’m less able to talk....if I’m getting better or worse if that makes sense. Thank you for all your help

I have dealt with that, and it can be awkward. I think at that point, sometimes it's worth checking in with the therapist about your goals and what you want to work toward. I've found that it can be difficult for me to keep conversations going if a client hasn't been clear about what specifically they are seeing me for. If it's just to vent, that's totally cool, but it's helpful to know. That, or if there's some kind of change that they are looking to engage in, because it gives me a chance to formulate questions that will keep the conversation going.

Honestly, more than anything else, having improv skills is what helps me most through these situations. I might use it to check in and notice that the talking has subsided, and ask if there is something specific I can do to help move the process along. Or I may just say that it's okay to not have anything to say - or if we need to hold some silent space of maybe even meditate, we could do that.

At the end of the day, therapy shouldn't feel like a constant pressure cooker of unsaid expectations. If there's a struggle, it's worth saying out loud to your therapist.

Can anxiety be successfully treated without medication? I don’t mean for 1 person out of 100, but for a lot or most people? In conjunction with therapy I tried an SSRI and on the very first dose had serotonin syndrome, which also completely put me off trying any similar medications. If you can’t tolerate medication, what are other options besides therapy alone that can be effective?

Thanks for the AMA!

It can, yes. I'm not a psychiatrist, so all of my work with anxiety is without medication. If it ever gets to the point that it seems like medication could help catalyze the process, I'll make a referral to a psychiatrist.

In my experience, I haven't had to do that very often. That said, working with anxiety can be very tiring and time consuming for clients because it requires us to unlearn a lot of things and then learn new things to replace them with. That's hard for the brain to do. It's a literal replacement of automatic thoughts and a reframe of our relationship to our own emotional experience.

Options besides therapy for severe anxiety is a difficult one to answer. Working through severe anxiety really is accomplished more effectively with the support of somebody who knows what they are doing. Finding support from good friends or online support groups can be helpful if therapy isn't an option. For things like minor anxiety, meditation, mindfulness, etc. can sometimes help.

Hi. Hi. Hi!!

I love that you are doing round 2, but I am almost out and about to hit round 3!!

I expect to close Round 3 tonight and get to Round 4.

So? Are you around for round 4 questions?

Also? Do you consult with your clients and explain that their obsession is actually a digression from reality, and that they should go outside from time to time?

I'm a bit confused about the first part of your question, but I appreciate you asking me one.

I tend not to make sweeping statements about that sort of thing - for many gamers, gaming IS part of their reality. The relationships built within them, the skills they learn, etc. And those skills can be transferred to real life. Is it also healthy to go outside from time to time? Yes. And depending on the treatment plan, that may be something I suggest. But I'd never tell a person that the thing they enjoy and hold dear is a "digression from reality".

Hahaha!

Ok. You took my troll as serious, and it kind of is.

I guess my question goes to the nature of people who feel gaming IS life.

In every generation we have people who dive deeply and ONLY into the common media of their time. Newspaper. Radio. TV. BBS. "Talk." IRC. ICQ.

Gaming is in a lot of ways merely another way of jumping into a form of controlled communication.

I guess my question is whether you roll with that and say "hey, so? This is your life. Let's find a way to make it healthy," or whether you say "there are trails and birds and squirrels and all sorts of nature out there, go see it."

I appreciate the follow up! And honestly, it could be a mix of both, depending on the person and what they are struggling with/ what their treatment plan is.

I think it is important to first meet people where they are at and then help them expand their horizons. So I'll meet a person at video gaming and build an alliance through that, and then if expansion to other hobbies is part of their goals, we work toward it together.

That's the best I can answer this without having a specific case to share.

Tap water or bottled?

Tap through a Brita filter and then poured into an insulated water bottle!

As a client if you feel your psychologist is doing something sketchy (video tapping you or hitting on you) what can you do to prevent it from happening to someone else without blowing up their professional life?

Honestly - if you're trying not to make a scene, just don't refer anyone to that therapist. Therapists live or die by referrals, so you could either a) just not tell anyone to see that person or b) if the name of the therapist gets mentioned, you could say "I didn't have a good experience with that person" and that will probably be enough to turn a person away from them.

Two things:

1. !wrongmotto

2. If you were to collaborate with other mental health professionals on stream, what topic areas would you want to look into?

So many. Psychiatry, EMDR, DBT, or really anything that a person has a clinical specialty in. I'm not the end-all-be-all authority on all types of therapy/ approaches, so it would be cool to get various types of representation to diversify the voices people get to hear from.

Hello,

I have a friend with anxiety who calls me when she's having an attack. She has paranoid thoughts about her finances. I've been suggesting to her to go see a therapist but she's hesitant to see one. How could I help a paranoid person deal with her anxiety attacks? Thanks for the response.

Recognize your own boundaries and ability to help. If you start feeling like you're being pulled beyond what you're capable of handling, I think it's important to set good boundaries and do as you're already doing - refer to a therapist.

If you're willing, sitting down with the person and helping them through the process could be super helpful. Sometimes it's nice not to feel alone and to instead feel empowered and encouraged when trying to find a therapist. It isn't easy and can stir up anxiety for people. Reassurance during the process could make the difference.

What are you best tips/processes for getting over a devastating break up?

Breakups are one of the worst emotional experiences humans go through because it's a severance of an attachment. Attachment figures are who we seek proximity to in times of stress, so we experience the distress of a breakup, want to seek proximity to the attachment figure (ex) but can't because of the breakup. That's massively distressing for us.

Finding supportive friends and family to rely on can be helpful. And I'm a big believer in going "no contact" when a breakup happens. Otherwise, we keep re-opening our attachment wound. Delete them off social media, block their number, and allow the attachment to move elsewhere (new relationship, self, family). That's really hard advice to take when navigating a breakup, but time and attachment healing really is the key to getting over a devastating breakup.

And it's important to be patient and compassionate to our emotional experience during breakups. It's a form of grief. And unfortunately people are sometimes hit with messages such as "get over it" and then feel a sense of pressure that just makes things worse.

Hello Dr Mick. Every time I have some sort of romantic feelings for someone and they reciprocate them my feelings for them switch off, like instantly. It literally happens all the time and I don’t know if it’s normal or should I seek help through a therapist?

It's more common than you might think. You're definitely not alone. A therapist could help you figure out why it's happening and build strategies for altering the response. It could be any number of things and I can't really speculate since you're not my client and I haven't done an assessment.

In general, something like that could be indicative of a person's attachment style/ experiences. A therapist can help sort that out and make sense of it!

What are you supposed to do when you can't afford therapy?

This makes me sad that so many people have to ask this question. I wish there were policies in place to make therapy more accessible to people.

That said, there may be a few options. First - many therapists (including me) will keep a pro bono client and/or sliding scale client on their caseload. Pro bono means no cost, and sliding scale means what a person can afford. Most therapists don't advertise it though. It never hurts to ask if you do some searching and find somebody who looks like they'd be a good fit.

If you have a university in your area with a clinical program, there's a good chance that students are seeing clients a low or no cost. And research shows that therapeutic outcomes between students and seasoned therapists generally aren't that different.

Finally, sites like adaa.org have affordable therapy finders.

If all else fails, local crisis lines are free and can be used to talk stuff out. I worked on one for three years and you don't have to be in dire straits to call. The person on the other end is trained to listen and help with problem solving. While not a therapist, it can be better than nothing.

Is toxicity in gaming a mental health issue? I admit I rage in overwatch all the time because of asshole teammates

I think it's more complicated than just saying it's a "mental health issue". If anything, I think it can be more of an anonymity issue. It's amazing how empathy and patience goes out the window when we don't have a person to connect to. It's kind of like driving - the car around the person makes it so much easier to be nasty.

I think that, combined with how much value many gamers put into their gaming and how much of their identity is tied up into it is a recipe for rage, hate, and vitriol. It's easy to outsource our anger to others in video games because we don't have to see the consequence of it.

As gamers, I think it's important to pay attention to our own emotional experience while playing games, and taking a break if it starts to become distressing. And if that becomes increasingly hard to do, therapy with a therapist who understands gaming can go a long way.

Honest question, hopefully it doesn't offend.

What's the difference between "anxiety" and "bad habit of worrying about things that just don't matter"? My wife tells me she's "got anxiety" and I'm having a hard time taking it seriously. I know I'm not being as supportive as she'd like and I'm trying, but frankly I have a hard time with it. It just seems like there's a simple solution.

"Does this thing I'm worrying about actually impact my life negatively in a meaningful way?" if yes, then find a solution. If no, then move on the the next problem.

For instance, she'll spend a half hour stain treating for a stain that I can barely see, on a $5 shirt for our 4 year old, who's just gonna spill ketchup again. Meanwhile, regular laundry hasn't been done in months. Then she gets upset when I just take care of my laundry myself, as if it were some sort of attack on the clothes. Not on her, but the clothes themselves. This is just an example of how she is with several things in our household.

No offense taken! I appreciate the question.

Anxiety manifests cognitively and behaviorally in many, many different ways relative to the person. Sometimes it's intrusive thoughts, sometimes it's repetitious thoughts, rumination, hypervigilence, etc.

No matter how it manifests itself, anxiety at it's core is an emotional experience, one that is worthy of validation and compassion. You'd be surprised how far "it's okay to be anxious" goes for a person when they can really internalize it. At the same time, we can hold others accountable for the behavioral manifestation of it. "I hear that you're anxious, and it's okay that you are. At the same time, I don't appreciate being blamed right now." Is a simplified example of how a person could respond to another's anxiety if the manifestation is blaming others.

Anxiety isn't rational. It's a risk-mitigating emotion that goes off the rails and takes over in ways it doesn't need to sometimes. Avoiding it or invalidating it makes it worse over time.

Good luck to you :)

Do you see Therapy as a permanent solution/something that should plan on going to your entire life/get you to complete recovery? Or do you see it as a stepping stone?

While I believe people obviously can benefit from therapy, I don't believe it is a final solution. I truly believe that people need to ultimately learn things themselves. Similar to training wheels on a bike, you can help them see what it is like to be in that better place and open their eyes to it, and hopefully point them in the right direction, but ultimately they need to be put out in reality by themselves and learn about themselves and life as an individual. I think humans at the end of the day will learn better and carry life lessons further when they go through them themselves and experience them alone than being told how to think and what to feel and how to navigate through it all.

Now each person is different, some will use it better as a tool than others, and I can only speak second hand on my ex girlfriend. She relied so heavily on her therapist. She thought her therapist was the answer. And when her therapist wasn't magically making things better, she fell into an even worse place and got discouraged. I compare this to people who use anti depressants and how a lot of them see them as a "forever answer", and by having this crutch they don't see the need to work on things themselves since after all "this is the answer - so why isn't it working?"

I won't argue these things don't have their place and that they haven't saved lives. But where do you as a professional believe therapy and medication lie on the scale of treatment for say anxiety and depression?

To answer that first question - it completely depends on the person/ system. For some, therapy is a lifelong endeavor. For others, it's an in-and-out as-needed. There's no right or wrong way to do it - so long as it's helpful and a valued part of a person/ relationship's health.

I often say "my job is to work myself out of one", meaning that I want to help people figure out how to navigate change/transitions/life in a way that they feel empowered. Sometimes its with my assistance, other times its them spreading their wings and going it alone. I think moving through life successfully is a balance of doing things on our own but also relying on others when needed. Making that distinction/determining which way to go in a given moment is an art and takes practice.

Medication 100% has its place. As does talk therapy. And, for some, they combination is what makes a big difference. I think they catalyze a person's agency to live their life and navigate the adversity they will inevitably experience. If medication can help take the edge off and talk therapy pushes it through, then thats awesome.

Part of what makes therapy so awesome is that it's unique to the person/ relationship. It's a big puzzle and there's no "right" way to do it (so long as we are acting ethically).

What do you think about the recent research finding psychiatric diagnoses scientifically meaningless? Do you think it is good to hex specific diseases into patients by giving them diagnoses that have little to do with reality? Do you see patients start identify with their diagnosis?

I'm not familiar with the research, so unfortunately I don't have a comment on that. If you'd be willing to DM me the research you're talking about, I'd love to look at it!

That said, I do see people start to identify with their diagnoses and/or emotional state. Depression is a big one. People who have struggled with their depression their entire lives will often start to build their identity around it (and not always consciously). It actually can make therapy difficult because moving toward goals of depression management, joy, happiness, etc. can actually run counter to the very core of who a person perceives themselves to be.

So, the first time the person experiences something joyfully, it may actually make them anxious, or they may be resistant to it and instead snap back to learned responses built around the depression identity. Being aware of the anxiety a person experiences when they start to alter their expectations of themselves and others is a key part to helping people move through change.

What is the common cause of anxiety for your clients? In other words, what usually triggers a patient’s anxiety.

This is actually hard to answer because the cause of anxiety can be so context-specific.

That said, it's usually caused when a person is perceiving some kind of threat (often the unknown). Anxiety is protective, and exists to help us mitigate risk, so anxiety pops out if we perceive some type of danger (not necessarily in the traditional sense - for example, with social anxiety it can often be a fear of "messing up" or "not knowing what to say").

It then becomes an issue when the anxiety is met with avoidance, reassurance-seeking behaviors, or invalidation. People are often able to manage their anxiety much better when they leave compassionate space for it and recognize that they can think and act in a way they choose even when the anxiety is present. I hope this makes sense!

Hey doc. I just got turned down for a job the other day. It occurred to me that social anxiety and performance anxiety caused me to fall short of my potential and not get the job. I’ve never had performance anxiety this bad before.

Do you have any tips, tricks, or suggestions about how to curb this anxiety in important situations?

It's so hard to do alone. If you have access to therapy, I really do recommend that. If you don't have access, I think it's important to acknowledge anxiety when it comes up so that we can decide how to interact with others/behave even though it's around. Avoidance or denial of anxiety makes it worse over time.

It might be helpful to role play interviews with somebody you trust, or practice building distress tolerance in situations that pull out some anxiety (for example, going to a bar that is filled with people you haven't met and trying to strike up conversation with somebody new that you haven't met) and allowing yourself to not do well or "fail". That's tough to do though.

Working through anxiety is often more successful with the support of somebody who knows what they are doing and can tailor the work to your specific needs.

I’ve been through a few bad episodes of life during the past three years, starting when I got expelled and then readmitted to college, my life partner shortly after graduation had a traumatic brain injury, and the death of close loved ones along the way doesn’t help much either. I’ve been out of college for 3 years now.

I’ve had the inclination to see a therapist to work through my anxieties for a while now. Is there a clinic you might recommend in the Boston area? Is there a type of psychiatrist you would recommend who specializes in social anxiety?

Unfortunately I'm not very familiar with the Boston area. I might recommend using a service such as Psychology Today or adaa.org to find somebody. Psychology Today has filters that can help you find what you are looking for. Call a few people who stand out to you and see how the vibes are. Go with who feels right!

My therapist says I have health-related OCD, causing me to have obsessive and intrusive thoughts about death and drastic health issues.

I get dizzy a lot (I have gone to doctors about this) as well as ice-pick headaches, racing heart, hot feeling in extremities and the head, etc...

My question is, is it possible for anxiety to cause such noticeable symptoms and why?

Yes, it absolutely is possible.

Anxiety is a risk-mitigating emotion. From an evolutionary perspective, anxiety protects us from what could potentially harm us or even kill us. Unfortunately, for many people, anxiety can manifest itself as intrusive thoughts, rumination, etc. At the end of the day, it's just trying to protect us from a perceived threat despite data to the contrary. It's trying to get our attention, but it overdoes it sometimes.

Re-framing anxiety as protective can be very helpful, and then working to alter the inner-dialogue we have with it from one that is adversarial to one that is compassionate can be incredibly helpful.

What is your favorite ice cream flavor?

Ben & Jerry's Cinnamon Buns.

Do you think video games can cause school shootings?

No. They're just an easy target that are convenient to blame and offload responsibility from what actually contributes to the event. A school shooting doesn't happen if the person who wants to do it doesn't have access to something that shoots (guns/assault rifle).

Violence and mass murder existed long before video games ever did. People who blame video games often do so because they don't actually understand how video games work and what just about all research has to say about it.

In fact, video games are more likely to facilitate transferable skills that are useful (leadership, social interaction, decision making, and problem solving).

Thanks for the ama! Not sure if this is an appropriate question, but since you’re a family therapist I’ll give it a shot lol

So about a few years back a redditor posted a ama about having a sexual relationship with his mother. Reading the entire ama, it seemed that despite the negative stigma of having an incestuous relationship, he came out of that affair “normal” and unfazed by it all. The mother, father and son were all ok with the situation, and he even stated his parent’s relationship improved(sexually).As a therapist, what’s ur take on this situation? Can you truly come out of that relationship normal? Would you consider this relationship as some form of Stockholm syndrome.

His background: white/upper middle class/ educated/ non religious. Incest relationship began when he was 14.

Here’s the Ama I’m talking about if anyone is interested: https://www.reddit.com/r/IAmA/comments/nmmjr/iama_man_who_had_a_sexual_relationship_with_his/

While I appreciate this question, I actually can't ethically comment on it. It's reckless and irresponsible for me to do any sort of profiling or analysis on a real person/ family system that isn't my client/ that I haven't met, especially in this public space. There's too much complexity and unknowns for me to be able to give any sort of meaningful answer to the question.

I think panic attacks are a breathing disorder because with specific breathing as thing techniques you can stop one in seconds. What do you think and why?

I think that's a bit of an over-simplification. Physiological responses are frequently connected to psychological experiences, though, which is why breathing techniques can be so helpful. At the same time, only learning breathing techniques, while helpful, leaves the psychological aspect out of it. Panic attacks are often the result of a cognitive spiral/ positive feedback loop where a person becomes anxious about having an attack, which inches them closer to one, which makes them more anxious, on and on.

Doing some emotional and cognitive work can be preventative, and the breathing skills can be used if the panic attack still happens or preemptively with the newly learned cognitive and emotional regulation changes. It's all connected.

Is life suposed to suck all the time or do I need therapy? It seems everyone is depressed these days, so maybe its normal and I just need to get my shit together. Thanks for your time!

Depression and anxiety are normal. They're just talked about more nowadays because it's become increasingly more acceptable to do so.

Therapy can help if your experience of anxiety or depression becomes significantly distressing. And there's no shame I'm going - I see it as an incredible sign of strength when somebody is willing to seek assistance to promote their own mental health.

The "suck it up" mentality can be useful at times, but also can be very invalidating. You feel how you feel, but also have agency over what you do despite feeling that way.

How do you talk to people who think e-sports is a legitimate thing without laughing at them?

The same way I talk to people who think going outside or reading a book is a legitimate thing. With curiosity and genuine interest.

We all have our interests, and what brings one person joy may or may not bring the same level of joy to another. Variety makes life interesting, and I'd rather not waste my time laughing at somebody for something they enjoy.