Mental Health AMA

Is it true that depression and anxiety can sometimes make it hard to remember things? I often find myself forgetting things easily.

Great question! They definitely can, I've seen this frequently with clients. Both of these diagnoses can make it difficult to concentrate, which means clients aren't necessarily "forgetting things" but they often just weren't very focused on it in the first place.
I also recommend a medical rule out just to ensure there isn't any medical issue as well. I ask my clients to see their medical doctor and have an annual physical with blood-work done.

What are some common mental health "warning signs" that people should be aware of & check with their doctor if they notice?

Good morning McCremuel! The signs can vary pretty widely depending on what's going on, signs of depression would be much different from anxiety. And even for the same mental health diagnosis, the signs can very widely from person to person. However, some of the common things we look for are changes in routines and how these signs (which mental health professionals usually call symptoms) are affecting the person's functioning. I.e. are they having issues managing their responsibilities in academic, social, and/or professional settings.
Is there a certain type of mental health issue you're referring to?

Thanks! No I didn't have any specific issue in mind. But I think people often don't know what might be a symptom of a mental health issue vs. what is just normal human mood/thoughts.

I guess what I'm looking for is: what's a common issue that suggests it might be time to speak to a doctor?

E.g., in the physical health world, if I found a wart on my finger, I wouldn't go to the doctor; if I found a hard lump on my testicles, I would go get a doctor to check it out. But in the mental health side, I have basically no idea where that line would be?

Great point! It can definitely be tough, and like JaL3L said, if it's been a long-term issue for someone, they might not recognize it as a problem. Some people do this with medical issues and with substance abuse issues as well. I think prevention is typically better, for both physical and mental health, so if someone has a change in their mental/emotional functions, or they are having issues accomplishing tasks/goals, it might be a good idea to talk with a mental health professional. For someone with long-term symptoms, while they may not notice any recent changes in their life, they may be getting feedback from others that they are showing symptoms, and they likely have had a hard time enjoying life or doing the things they want to do.

What are some good practices for helping someone who suffers from anxiety and depression and have become extremely dependent on you?

It can sometimes be overwhelming and exhausting but any attempt to pull away is seen as abandoning them. Are there methods for asserting your own need for space whilst supporting them as best you can?

Hello GentelmanNerd!
Good question, I often work with clients who want to have more boundaries with others. It can definitely be tough, especially when it's someone we're close to and it's a long-standing relationship, or the person is going through a really rough time.

Here's what I tell my clients when they want to set a boundary, a lot of this is borrowed from the DBT (Dialectical Behavior Therapy) skill called DEARMAN:

1. Tell the person how you're feeling about the situation using "I statements". Don't tell them what they're doing wrong (this is a you statement) but tell them "I feel overwhelmed right now", "I feel tired because I haven't been hanging out with friends" etc.
   
2. Be clear about what you want and give the person a timeframe. i.e., "next month I need to have Tuesday nights to myself", or "Next week I'm going to start going to bed earlier and won't have my phone on after 8pm", "next Saturday I'm hanging out with friends all day"
3. Tell them why you getting what you want is good for them too. "If I get to bed earlier, I'll be in a better mood when we hang out", "time alone or with friends helps me recharge, so I can be better at supportive you".
   
4. Ask the person if they want help finding other ways to cope with what they're going through. E.g., do they want helping finding a therapist, finding a doctor, getting a gym membership, etc. Sometimes people do want this help, sometimes they don't, but if we try to guess and try finding an answer without knowing what they need, we can get pretty frustrated and resentful, so encourage them to tell you what else you can do to help.

What's your take on psilocybin assisted psychotherapy?

Hello levader,

This is a question I hear frequently, but it's definitely not my area of expertise, so I don't feel qualified to have an opinion on psilocybin or psychotropics in general in regards to psychotherapy.

My primary issue with this is consistency. We know that a 50mg pill approved by the FDA is going to have the same makeup as another pill of the same type/size (with rare exceptions). But for anything unregulated, the potency/chemical makeup can vary dramatically. And even if the chemical makeup was always exactly the same every time (which it's not in the real world unlike the labs that are used for research), it's difficult to ensure the same amount is used every time, or that other variables are controlled consistently.

Here's a pretty thorough article about this and other substances used in conjunction with psychotherapy: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6041963/

Towards the bottom it discusses the challenges with using this type of treatment and how various factors can cause results to change.

How do you decided what to diagnose a patient with for example schizoaffective disorder vs ADHD vs Anxiety Disorder vs Autism Spectrum Disorders when there is quite a number of systems similar to each of the conditions. Is it a matter of which one ticks the most boxes, which one suits the current prevalent symptoms or do you go with comorbidity? I am interested as I have had diagnoses in the past starting with schizophrenia then bipolar then discussions about autism spectrum and so forth. I am aware also that this is more of a generalization as opposed to looking at a specific patient.

Hello Ickyt,
This is a great question! And this is something I regularly see mental health professionals struggle with. I've had many clients over the years who have had their diagnose change over the years from various psychiatrists, therapists, etc.
Yes, it can often come down to which one ticks the most boxes, and looking at the differential diagnosis criteria in the DSM. These guidelines are meant to help practitioners avoid mixing up diagnoses, but it still happens.
I don't have a lot of experience with Autism, I've definitely seen anxiety and ADHD misdiagnosed a lot, even by really good mental health practitioners I've known personally. I've found ADHD a particularly difficult one to diagnose, not just for clients I've worked with, but for other mental health professionals as well. The book "Driven to Distraction", written by Dr. Hallowell, is regarded as one of the best ADHD books available, and the author is one of the most well known ADHD psychiatrists in the field. However, even Dr. Hallowell, who's considered an ADHD expert, didn't realize he himself had ADHD, and went diagnosed for years even after this had become his specialty. Even the top experts find it tough to diagnose this stuff sometimes.

I think this confusion over diagnoses happens for a variety of reasons:
1. Symptoms are only subjectively reported (for now). There's no objective testing for most mental health issues, i.e. a bloodtest or MRI, etc, like there is for most other health issues.
2. Symptoms vary widely from person to person. Some depressed people shows signs of anger, some withdraw, etc.
3. Like you said, there's a lot of overlap with diagnoses. And sometimes the things we think are opposites can share similarities, i.e. I often see a lot of overlap with anxiety and depression, even though we typically think of them as opposite side of the mental health spectrum. ADHD and anxiety both can manifest as an inability to sit still, lack of focus, racing thoughts, etc. And this can be tough for even experienced professionals to differentiate.

My advice to my clients who feel they don't have the correct diagnosis is to get a second opinion and have both practitioners work together to help make the best diagnosis possible.

What's the best way to stop a downward spiral of anger?

I get mad at something minor, then my lack of control makes me more angry. Hopelessness and cynicism pile on, and I'm full on ready to destroy. I shouldn't Identify with the Hulk, but my secret is I'm always angry.

On a related tangent, my doctor put me on adderall for ADD (which I hated and stopped taking due to additional fuel to the rage fire). I've read that there is some link to focus control and anger issues. Is it true that not being allowed to focus on what I want, or control my focus, could be a source of anger? I never would have related the two and haven't found much literature on the subject.

Hello SoundAdvisor!

The top thing I recommend to my clients dealing with anger, is prevention! It's so hard to get calm when we're already in the red zone. Preventative treatment is better for pretty much everything, and anger is no different.

I recommend my clients look at their most recent anger episode, then we discuss the following (this is following the format of behavioral chain analysis used in behavioral based therapies like CBT and DBT):

1. Prompting Event: What happened, objectively describe the situation. I.e. it was 5pm on Wednesday, I was walking down the hallway, my coworker walked into me and spilled his coffee on my white shirt.
2. Interpretation: What was the thought/judgment about this situation. I.e. "my coworker is a jerk and is inconsiderate", "he's an idiot", "he ruined my day", "he knew I was there and did it on purpose". We also look at challenging these interpretations. Do we really know the coworker did this on purpose? Did he say so, do we have other evidence to support these interpretations from the objective description in step 1? If not, we may need to challenge this assumption/judgment and think of it another way. I.e instead of "he did it on purpose" we may change this to "he was looking at his phone and likely didn't see me". The interpretation is important, as it may not create the emotion entirely but it can definitely magnify it.
   
3. Impulse: What's the very fist impulse they client had. I.e. "I wanted to yell at him", "I wanted to spill my coffee on his shirt", I wanted to punch him", etc. This is what the client wanted to do in the moment, not what happened or what they logically think is correct. It's just that first primal instinct.
4. Reaction: what did the client actually do?: Did he yell at the coworker, run to the bathroom, smile and say it was fine, throw his phone in anger, etc.
5. Fallout: what was the result of the client's actions: I.e. the client yelled at the coworker and now the coworker avoids the client.
6. Vulnerabilities: This one is so important! This is the part about prevention. What physical and psychological issues may have contributed to the anger outburst. I.E. was the client hungry, tired, didn't take a break, poor sleep the night before, argument with partner this morning, anxious about something else, had a past negative interaction with this person, etc. This is where we start to work on making lifestyle changes that can help the client avoid getting in the red zone in the first place. Better self care, healthy assertive communication, taking time for self, breaks, walks, awareness of early stages of being upset, practicing breathing techniques/meditation regularly instead of only when they're really mad, etc.

Most clients push back against the prevention idea at first with excuses like: "I don't have time for a break", or "I'm too busy to have lunch", and initially just want a quick fix.

I tell my clients that whatever they think would help in the moment is something they need to practice regularly when they are calm. Like most things, we can't be good at something if we only do it in times of pressure or distress. We wouldn't tell a professional basketball player to only shoot free throws in a game, we'd tell them to practice alone in between games, then when the pressure is on, they'll have a better chance of making the shot.

It wasn't that long ago that homosexuality was listed in the DSM as a mental health disorder. Partially because of the social construct at the time. How can we be sure that other mental health disorders listed in the current DSM aren't based on social constructs? For example, hypersexuality in women. A therapist might diagnose this in a woman because they believe in a social construct of women's sexuality and can't see alternative sexuality as anything but a mental health disorder. I realize that "normal" behavior is a social construct, but I hope we are moving toward a society that is more willing to expand beyond normal behavior. I'm guessing if the behavior causes harm will be a criteria, but again, that can be a social construct if a therapist believes the behavior is wrong.

Hello lifeisapeach,Excellent and thoughtful question! This is something I think about too, and I've also seen how the rigidity of these manuals/guidelines have had a negative impact. I think the best way to avoid this in the future is to have a variety of voices included when making these guidelines and diagnoses. Rather than just straight white males like it has been in the past (I'm a straight white male, so I'm not hating, just stating the facts). I think allied health professions (like counselors and social workers) need to do our part by speaking out individually and collectively to ensure that these tools/manuals are balanced and fair, and include as little bias as possible.

I’m always curious to hear from other providers/helping professionals: what do you do to monitor for, prevent and address compassion fatigue and burnout?

Hello!
Good question. This is such an important issue for helping professionals! When I work with people who are looking to go into a helping profession, I always stress the importance of self care. Those who go into helping professions are generally caring people, but this means they often neglect their own needs at the expense of helping others (I've been there so I'm not judging). While their intentions are good, sacrificing self care doesn't really help others in the long run, as these same professionals can get burned out and quit their job, leave the profession, stop caring etc.
I think for someone to make it in these types of jobs, they need to give themselves permission to shut off at the end of the day. It's ok to not think about work when you're off the clock. It's ok to leave on time, take a break, take a vacation, etc. These sound like simple and obvious things, but so many helping professionals don't do them because they have this impression it's "selfish", even if that's now how they might describe it. Ironically, the work cultures in many helping professions often don't support the self care of it's employees. For example, I've worked in several hospitals, government agencies, and non-profits, and there's often a lack of staff, push back when requesting time off, long hours, excessive paperwork that keeps people working late, etc. I had to learn long ago, that's it's ok to say no, to switch off and enjoy my life. If I hadn't learned that lesson, I probably wouldn't still be in the mental health/healthcare filed.

Have you heard of or played Hellblade: Senua's Sacrifice? It's an action-adventure game that took ambitious steps in exploring mental health and psychosis. Senua, a warrior struggling with psychosis, must not only overcome physical challenges, but also those presented by her mind.

The award-winning game was a hit. But it also proved to the team that there was a place, as well as a need, for more games that carefully represented mental health

I wonder what your thoughts are on the representation of mental health in the video game, and how it best correlates to the struggles of real life challenges.

Hello!
I haven't played Hellblade, but I have heard of it and have had clients recommend it to me. I did look into getting it at one point, but it looked a bit too intense for me.
However, I loved Celeste! I know it's a completely different genre, aesthetic, etc, but I thought it was really well done and felt a really strong connection to Madeline and her journey. I liked it because it dealt with mental health in a positive way, and didn't stigmatize it. I think games that can incorporate mental health in a natural and positive way are great and I've love to see more!

Thank you for your response!

Celeste is an amazing game, albeit quite difficult at times. I certainly see what you mean regarding dealing with mental health in a positive way. Senua's Sacrifice is more horror themed, and tends to lean on the darker sides of mental health. I can't claim to know much about the topic, but I understand more now given your insight.

I appreciate your response and incorporating a different game into an example, since you hadn't played Hellblade.

No problem! I've heard good things about Hellblade, but I just like more lighthearted stuff.

Yes, Celeste is tough! After I beat the main game there were some extra levels that were just too hard and I never went back to them, maybe one day...

Is there any evidence to suggest that today's youth (Gen Z, late Millennials) are significantly unhappier/ more stressed than generations past?

Cheers, thanks for doing this AMA.

Hello!
I've definitely heard this a lot, and it would seem there's more pressure/stress younger generations. There's also research to support this:
https://www.ualberta.ca/folio/2020/01/millennials-and-gen-z-are-more-anxious-than-previous-generations-heres-why.html

https://www.multivu.com/players/English/8294451-cigna-us-loneliness-survey/docs/IndexReport_1524069371598-173525450.pdf

The second study is from a sample of 20,000 and shows generational differences in lonliness (page 6), with gen z being the lonliest.

These studies and others attribute this to various factors, social media (creates more pressure, unrealistic expectations, FOMO, comparisons, etc.) And other factors such as more mobile technology which makes it easier to have constant distractions or be disrupted any time by app notifications, friends, bosses, parents, teachers, etc.

I believe my sister has undiagnosed severe anxiety, depression, and agoraphobia. She doesn't leave her house (even before the pandemic) doesn't have friends, a job, or any social interactions outside of her immediate family. She blames those around her for all of her unhappiness and isolation.

We have tried to get her to counseling/therapy, but she has always given up on it before any progress can be made. I believe she would greatly benefit from therapy and/or medication, but what do I know?

Can you offer any help or guidance on how to get someone else into therapy, or something I can do to encourage/help her find treatment?

Thanks!

Hello JackSpade21

I know that has to be hard to see someone you care about struggling. I know it can also be really frustrating when you have a good idea of what could help but someone isn't' willing to try it, or gives up quickly.

To my clients who are in a similar situation, I suggest they ask their loved one what/if they can do to support them (I'm sure you have done this already), but a lot of times I find my clients don't ask others what they need and they just assume the solutions that would help them would also help their loved one. If someone is asking for help finding a therapist, I'd say help them search, but if they want support some other way, I'd suggest doing that.

I also encourage my clients to practice acceptance and being non-judgmental. I ask them to really validate their loved one's feeling, show empathy and don't have a judgment or try to fix the problem, even if they disagree. (I only recommend this when there aren't any serious safety issue.) Here's a great video by Brene Brown on empathy: https://www.youtube.com/watch?v=KZBTYViDPlQ

Most people are smart enough to know what options/solutions are out there (I'm sure this includes your sister), and most people knows the things they could do differently to change their life. Most people don't need someone to tell them what they've already heard or already know, and this can cause them to pull away or even feel like their intelligence is being undermined.

Most people who are having a hard time are already being very hard on themselves, so getting judged by others can feel they're being kicked when they're already down. I suggest just try listening and acknowledging what a loved one is feeling, and to let them know we're here for them, that we care about them, and we will help however we can (even if that's just listening without judging).

Hope that helps!

I've worked with a couple of therapists and it was nice talking to them but I didn't really feel like they were ever able to help me make significant change in my life. It was also very depressing to acknowledge that they were only talking to me because I was paying obscene amounts of money to be there.

If I were to seek therapy again then is this all I can expect from it or is there something I should be looking for?

Hello Stereoparallax,

Thanks for being here today, good question, that must really be a bummer to spend your time and money on therapy and feel it hasn't been helpful.

Firstly, I'd suggest being really clear with the therapist about what's working/not working and encouraging them to allow time at the end of the session for you to give them feedback about how you felt about that day's appointment. Also be sure there's time at the start of session for agenda setting so you can say what you want from that day. This could help the therapist get on the same page as you. I love when clients give me feedback, even if it's that they want to go in a different direction with our sessions. A therapist should definitely be open to getting feedback from you or changing that day's agenda if you want; if not, get a new therapist.

Also, sometimes it's just a matter of finding the right therapist, I'm very direct and focus on behaviors with my clients, which works for many of them, but some would rather process past issues in more detail, and that's fine, but it might mean I'm not the right person for them. I'm always happy to help a client get connected with another therapist if they don't think I'm a good fit.

Lastly, you're right, therapists are paid, and I know that can't feel good to think the therapist doesn't care and just wants your money. Most helping/wellness professionals are paid; teachers, fire fighters, doctors, physical therapists, yoga teachers, paramedics, soldiers, etc. I really like my primary care doctor, and I think she genuinely cares about me, but her practice has never once let me in to see her without me paying first. I don't think that means she doesn't care, it just means it's her job and she has to make a living. I'd love if our practice could offer all our sessions for free, but if we did, we'd go out of business and then we couldn't help anyone. Most therapists don't get into this field to get rich, if that was our priority, we would have gone into another field. We have to have a master's to be psychotherapists, so it's a lot of time and money to get our degrees and licenses. That being said, I can't speak for every therapist, and if you really felt the therapist didn't care, I'd recommend finding someone else.