We are Therapists hosting a R-Rated podcast called "Pod Therapy", Ask Us Anything for Mental Health Awareness Month!

Being able to schedule with a new therapist is a massive bar to being able to access care. Current health insurance providers seem to have minimal incentive to make the process easy or accessible.

What is your suggestion on how, under the current system, to help friends and family find the care they need given that often finding a provider is a task almost as hard as convincing a person to seek the help in the first place?

You did it! You asked the golden question! I hope this gets upvoted alot.

So I expected this question and blogged about it in anticipation, but here is a quick rundown of how to find a therapist.

Will you be paying out of pocket?

1. Search Yelp, Google or Psychology Today to find therapists in your area. All therapists take out of pocket patients, pick whoever you like.

2. Search for telehealth therapists if you are comfortable with that, I’ve been practicing telehealth for the past 2 years and I can honestly say the difference is minimal.

Do you have insurance?

1. You may have a phone number on the back of your insurance card to call for mental health care.

2. Go to your insurance’s website and download the “provider list” for mental health. Start googling the names of providers and see if any of them are a good fit.

3. Go to PsychologyToday.com and search for therapists by Zip code, filter those results by your insurance. You can also filter by specialties, but keep in mind most therapists are competent to treat most things and will tell you if they aren’t, so don’t over think it.

Are you or your spouse/parent employed?

1. Contact your Human Resources department and ask if your company has an “Employee Assistance Program” (EAP). You may receive access to a therapist completely independent of insurance.

Uninsured and Unemployed?

1. If you have your states insurance (Medicaid etc) then contact them for the provider list or search Psychology Today. It isn’t the case that Medicaid therapists are lesser in quality, there is usually no difference.

2. Search therapists in your area and filter by rate they charge. You’ll find many therapists are in their “Intern” years, this is sort of like a learners permit, they are practicing therapy under the supervision of a master therapist. These are great lower rate options. You can also contact therapists and ask if they have a “sliding scale”, this means they will charge some patients less if there is a financial difficulty.

3. Contact your state Universities and ask if they have a program where graduate students practice counseling. These are usually nearly free for patients and exist so therapy students can get hands on experience.

4. Are you religious? Contact your church and ask if they have any options. Often religious institutions have lists of professional therapists they partner with and are happy to pay the bill for.

What's the best way to tell if you're not progressing in therapy because your therapist is not a good "fit" vs. the modality isn't the right one for your presenting issues?

Hi Eyelashchantel! Great question!

So a couple of thoughts on this.

1. If you aren't progressing - regardless of the core cause - I want you to discuss this with your therapist. Alot of people are nervous to bring this up, but one way you could is to ask if you can discuss your goals and treatment plan with them. Then share that you feel stuck, as if you are not making gains. Then ask if they have any ideas to help you keep moving forward. Your therapist might give you some perspective you hadn't noticed, or they might have some materials they didn't think youd be into, or they might bring up a therapist change (Ive done this lots of times) or they might give you some feedback about areas that maybe they have asked you to try things but you haven't been willing to.
2. For decades the science has told us conclusively that the greatest predictor of patient outcomes is not the modality used, but the relationship with the therapist. Lots of people overthink the method (CBT, EMDR, DBT, etc) but really they should be focused on the connection she share with the therapist. If #1 above doesn't help, I'd consider a new therapist, but dont give up and don't feel that you need to swap therapists every time you feel stuck - sometimes stuck is part of the process.

What do you feel differentiates a "therapist" from a "conversationalist"?

Every therapist I've met with seems content to fill 50 minutes by asking enough questions/prompts to keep me talking, but never contributes much insight or analysis. The general impression I get is that they believe that if a person speaks and is heard by another person (regardless of any attempt to "work out" problems or insight or constructive input by the listener) this has some sort of theraputic value.

It never has for me, though. It feels like a waste of time and if I stayed at home and talked to a wall I would get as much benefit. Whether another hears it is irrelevant if that hearing doesn't result in more insight than I could come up with on my own.

Hi Watchitbub (Logan, I assume) great question!

So first you're spot on! The posture many therapists take is eliciting content from the patient by asking questions in sort of an interview format. We usually have a method and a direction we are trying to steer you, and our overall goal is usually to help you experience the "emotional yoga" of encountering your truth in safe place.

However, there are many people like yourself who don't much benefit from that. When I have a new patient I always ask them how I can be the best therapist for them. Sometimes they tell me what you did, that they enjoy and want direct feedback, challenges, and analysis. I usually warn them that they will still have to remind me sometimes or invite me to give that to them, but that I'm willing to.

The reason you need to invite that feedback from a therapist is because we usually default to a supportive posture rather than examining or critical. If you want those things you'll have to ask as they are off menu =), but they totally exist.

I encourage you to invite your therapist to give you more direct analysis and feedback. If their answer feels flat, tell them so, they might explain where they are coming from and why they stop short of saying something sharp.

Hang in there friend!

There are many options now for virtual therapists, some entire companies based soley on quick 30 minute sessions online. Sometimes even through text message instead of video call. What are your thoughts on these services? How does their effectiveness differ from in-person sessions?

I have to be careful how I answer this.

My official answer is that I am glad more options exist, and that people who might not have tried conventional methods are trying these new approaches. I am always on the side of more mental healthcare not less, so I support these new efforts.

Having said that, I also hope that these companies are doing a fantastic job of triaging patients whose situation indicates more traditional therapy, and that these companies aren't just dumping these patients because they need real help.

Also, if any of you online companies want to give our podcast money, DMs are open =)

One thing I noticed about my own mental health (long-term dealing with social anxiety), is that I seem to have lost the ability to 'take in' positive experiences. e.g. I have a bad experience in a meeting, I'll remember that years later and it'll make me nervous in that situation again. But if the meeting goes really well, it just kind of gets erased and the next meeting it's like I'm a nervous rookie all over again. It's like that with any kind of social interactions.

I'm just wondering if that kind of thing is common? (Not looking for free therapy! :) I just see the same kind of 'emotional forgetfulness' from family members too, so am wondering if it's a well-known pattern).

Hi Whoo me!

So not only is this common, we have words for it!

You've probably heard of "Cognitive Behavioral Therapy", well in that theory we have a list of broken perspectives people develop - think of them like bad eye glasses - that if you look at life through those lenses you'll see things in all sorts of inaccurate ways. We call those broken glasses "cognitive distortions".

The ones you are doing are called "Mental Filter" and "Disqualifying the positive". The first is when our brain only notices whats wrong and is blind to the context of everything else - like a person who notices the tiniest flaw on a beautiful wedding dress and then fixates on that flaw to the point that the 99% of the dress that is flawless is invisible to them. The second has to do with being incapable of considering what good things we do or are. Compliments fall off us without leaving a mark, and we have a very poor understanding of our value in general.

I encourage you to do more research into cognitive distortions, I think you'll find alot that you relate to!

Any advice for people that have burned out and lost interest in repeatedly starting over with therapists?

Other than the "gotta keep getting back on that horse till it rides" cliche that feels very similar to "get over it".

Hi Grodd, great question -

So first, please dont ride your therapist. Most of us have back issues from sitting in chairs all day.

Haha! Ok now seriously.

This is sadly a common thing. The nature of the mental health field results in therapists changing roles and patients losing contact. Students graduate, Interns advance, fully licensed therapists move agencies, insurances change coverage and provider lists, there are just a ton of things that can interrupt consistent therapy. So a few thoughts:

1. Yes, Im going to encourage anybody who has had a care interruption to not give up. I like to see mental health as a puzzle you are assembling, and each provider you meet may have a piece of that puzzle in their pocket for you. Approaching each encounter looking for that puzzle piece can be a positive way to go through the process. But, you're right, its daunting to recap the negative experiences that brought us to therapy in the first place with new people.
2. If its possible for you, consider looking for a private practice therapist. Those therapists are stable and can work with you for as long as you want to. Even if there is an insurance interruption they will probably offer you a fair out of pocket rate. That consistency can really be worth it in the long run, especially if you've already been disappointed by the interruptions so far.

Hang in there my friend, Im proud of you for not giving up and doing the next right thing. Healthcare is always inconvenient and disruptive, but never give up, work it because you're worth it!

How do you find a good therapist or know someone is going to be right for you?

Hi Simer! Thanks for asking such a great question!

So to be clear, I interpret this question as different than "how do I find a therapist" in general. Im sure I'll answer that somewhere else, but I also blogged it just in case.

The most important predictor of success in therapy is the connection you have with the therapist. So when you are looking for one I think you should focus on a few areas:

1. Competence - Does this person appear professional to me? Do I feel respect for this person? Do they seem to know what they are doing?
2. Convenience - Is it relatively stress free to use this therapist? Nothing will erode your therapy faster than choosing a path that is unsustainable for you financially or practically.
3. Connection - Can I get a sense of this person's humanity, and does that feel like a good fit to me? Do I like their photo? Do I like their bio? Do they seem to have a personality that seems familiar to me?

In the end Simer, never let perfection get in the way of progress. Think of the therapy life as a puzzle, many people have pieces of that puzzle in their pocket for you, the first therapist you work with WILL have something for you, even if that isn't your long term therapist.

Good luck friend!

What are the alternatives to therapy/talking treatments besides from medication?

Hi Aaron! Great question.

A lot of people don't appreciate the power of a good workbook. Im a big fan of workbooks that focus on particular issues like trauma, anxiety or depression.

For folks who don't feel ready to talk to a doctor or a therapist, I'd be super proud of them if they browsed some self help books on Amazon, or started listening to mental health focused podcasts or programs.

Those are all good places to start - but of course they are not a replacement for the clinical tools of therapy and medicine. Its ok to need those clinical tools Aaron, don't be afraid to get help =)

I've reached a point where often I find it easier just to be quiet and not even explain my situation to those around me. Is there a name for this phenomenon?

Hi Master -

First, Im proud of you for sharing here on reddit. Im sure you dont usually open up about this, and its good practice that you did here.

Second, yes its very common to offer silence to the world rather than try to unpack our truth. That isn't always unhealthy, and I think introverts often get a bad wrap. However we want people to find that voice to language their experiences and inventory their emotional truths. You can do that in a journal if you like, or an audio journal, or a support group, or an online community (like ours!). However you express that voice, I hope that sometimes you will =).

Hi guys, love the podcast!

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What are your thoughts on the growing field of psychadelics being used in therapy (psilocybin, MDMA, etc)?

Here comes my most downvoted response...

The FDA has reported some exciting research that may reveal Psychadelics as a whole new branch of medicinal therapeutics. This is ground breaking because it has been a long time since we have had any medicinal breakthroughs in mental health. I'm super excited for where this could go.

However, there is so much irresponsible behavior that so incredibly dangerous around this issue. Everybody has a friend who says their life was changed on a hallucinogen and now people are micro dosing or whole sale diving into to this very powerful drug field seeking mental health benefits. In my opinion, that doesn't work well.

All medicines can cause harm if used wrongly. The science of pharmaceutical therapies involves closely studying dosages and supportive elements to maximize results and minimize harms. Unmonitored, unregulated psychadelic use is dangerous on average an a poor substitute for mental health care.

Science once said that something in cocaine was useful, then influencers started using coke and celebrating it, that unmeasured approach lead to poor results. I think that's happening here too.

But overall Im eager for the science to develop and new tools to hit the shelves. I just hope we can help people do this effectively and not cause new harm among vulnerable populations.

Do you know what's delicious for mental health? Snacks. What are your favorite snack foods? Also, if Jacob eats anything else besides whiskey let me know. Thank you for doing what you do. I have listened to every episode.

I (Jim) got Nick a box of worldwide snacks which turned out pretty great. Jacob is the most cultured of all three of us, so he likes all kinds of snacks, most of which are alcoholic.

As for me, I like these little peanut butter chocolate cups from Trader Joes.

I've been diagnosed with schizoaffective disorder bipolar type. I suffer from delusional thoughts quite often and even though deep down I know my delusions are just delusions, I just can't seem to shake them.

Why is it so difficult to dismiss delusions even when we have no evidence to back up said delusions?

Hi Redditor, great question.

So first, I'm really glad to hear you have a diagnosis and are working on this. Hopefully your treatment team will help you identify the medicines that help with this exact problem, and the great news is that those medicines make a HUGE difference and work really well - but sometimes it takes a while to find just the right blend of herbs and spices that work for you, so don't give up.

So quick educational moment: Hallucinations are when you hear/see things that are not there. Delusions are when you wrongly interpret the world around you - for example - you develop paranoia and believe that you coworkers are part of a conspiracy to have you arrested.

Delusions are hard to dismiss because they flow from an internal place. Our brain quickly connects unrelated dots and looks for exotic interpretations of common things. It takes a lot of training and care to help our brain stop seeing the world that way firstly, but the good news is that it does get better.

Your therapist will probably teach you about Horses and Zebras. They'll probably teach you that when you see a situation you should always look for the "horse explanation" which is simple, boring and common, rather than the "zebra explanation" which is exotic, rare and exciting.

It will take time friend, but trust your team and do what they tell you, this will get better.

Is it true that most therapist don't know what to do with bpd patients?

Ok, so yes and no.

It is true that there are two populations that some therapists will confess behind close doors to feeling intimidated by: Borderline Personality Disorder and Co Occurring Disorder (Addiction + Mental Health).

The reason that some therapists are intimidated by BPD is because the nature of the pattern the patient experiences is volatility in their relationships, and this is likely to show up in the therapy relationship as well. I've personally treated lots of BPD (it doesn't scare me) and I know how to handle those patients. One day they will "break up" with me and tell me I'm not good at being a therapist, a few days later they will tell me through tears that they cannot live without me. Its totally ok for me because I've worked with it and know what to do.

New therapists can be caught off guard by this, and its difficult for them to have the steady hand earned through experience to know what to do. So that's why BPD has a little bit of a stigma to it even among therapists.

But please dont read any of the above to say that therapists cant/wont treat this. If you have BPD I encourage you to search for a therapist who practices Dialectical Behavior Therapy (DBT) as this indicates they not only understand BPD but specialize in its treatment. MOST therapists treat BPD without problems, but some rookie therapists might not feel ready for that, which is ok.

Great question!

Sooooo... I'm currently going through a divorce in California. We have yet to have our court dates, and I am still reeling* from her decision to end it. I just found out that she is sexually active with other people and I am utterly losing it. What could you recommend I do for my mental well-being during this?

Hi MusicIsTheWay -

Man, I'm really sorry to hear this. Its devastating to discover our partner wants to end the relationship in general, but then to learn they have already moved on gives us no chance for closure and feels like we have been discarded like garbage.

Its especially difficult because usually our partner is our "person", the one we would have come to when we are hurting in life. When they are the cause of that hurt, and they are moving out without us, we can feel completely alone.

I strongly encourage you to get into therapy as soon as possible. The therapist might encourage you to look into a grief or divorce group as well, but you NEED humans right now Music, do not attempt to do this alone. Get with your people: Friends, family, neighbors - anybody who you have a warm connection with. They may not be able to hold all the feelings you are wrestling with, but they should be able to give you that perspective of life being larger than this marriage, and you have worth beyond what your ex spouse could see.

Music, Im sorry this is happening to you, and I know you cannot believe this now, but its going to be ok. None of us is our worst moment, life is an average of billions of experiences, you have so much ahead of you. One day, you will have peace.

Be well friend.

Is everyone's mental health worse now than it was in previous decades? Or are the problems all the same but these issues were ignored more back then?

Both. I think we are experiencing acute distress from exhausting world conditions, and data suggests that previous generations have had similar experiences during social turmoil.

And also I think we are doing better at language our struggles and talking about them, which causes us to notice these mental health realities more often.

How do you know if your problems are “worth it”? What is considered not really good enough of a reason for therapy?

Great question! This comes up alot.

So first therapy is for everybody. Yes, insurances have sometimes made it annoying to get help and the therapist has to justify things, but we are used to that and its not your problem its ours.

You're allowed to go to therapy for anything. Maybe you're just feeling stressed or overwhelmed. Maybe your curious about how your past has created your present. Maybe you want to identify and disrupt patterns in your life that have caused you to be less than successful. You dont have to have a clinical diagnosis to talk to a therapist, the only qualification is that you are a human.

Unless you are a puppy. I will also treat puppies.

Has there been any discourse in your field about "self-care" culture and how the media has used it to atomize deeper structural problems with capitalism?

I feel like it's gone from "talk about mental health issues to destigmatize it" to "practicing self-care by showing off my expensive restaurant meal!" Or "Depression and anxiety from working full time at min wage and still can't make enough? Therapy is the answer, not $15 min wage!"

Hi Cramtastic -

REALLY great point. You're right, corporate America has offered breathing exercises and yoga memberships instead of financial compensation and healthcare benefits.

We once discussed a study that showed the direct correlation between having money https://www.spreaker.com/user/10313270/ep-146

I'm all for mental health being talked about and destigmatized, but helping people cope with the difficulties of life is no replacement for improving people's lives.

Mine is not a question about me but mental health in general

Why are people so much angrier now than they used to be. And so quick to vent that anger, often at strangers? Pandemic aside, people just treat other people worse, and there seems to be less filtering of thoughts.

My guess is a couple of things:

1. The internet has made is possible to speak to others in a mob voice. Caustic and hateful, uninterested in nuance and not curious about anything. You give that voice to enough people all the time and things can seem yucky.
2. The pandemic messed with a lot of our social skills. I think many of us are still relearning how to be good friends, neighbors and coworkers.

Stay positive my friend, this thread is a safe place with lovely people in it who are rooting for you =)

Oh man. I was ghosted by my last therapist after 10 years. His behavior was really abusive towards the end and it's ultimately positive he's no longer in my life, but I am still struggling with the damage he caused and it's been almost a year since he ghosted me. I'm also realizing that he misdiagnosed me in a malicious way and turned my symptoms around on me, going out of his way to trigger me and make me feel helpless.

I am working with a new therapist but I'm finding it very hard to make any progress. I'm also constantly going back and forth with thoughts of writing to my old therapist about his abusive behavior towards me for closure, and I've also looked into reporting him. Any thoughts, suggestions for me?

Hey Blackmetallic -

First, Im so sorry to hear that such a long relationship with a therapist ended so poorly. A 10 year run is rare, and Im sure there were times the two of you worked well together, but it appears that things ended in a toxic and painful way.

I'd probably not advise you to reach back out to that therapist. I dont see any healing through that for you, and selfishly I want you to do what is going to move your life forward. Im glad you are talking it out with your new therapist, and I would defer to their recommendations as they know your case so intimately.

As a general rule therapists are not supposed to ghost patients. When possible we want to refer them to other therapists and explain why we need to stop working with them. Sometimes the situation becomes a little too intense, maybe things were said that felt too personal, and the therapist may feel justified in just terminating the relationship without any due diligence.

I encourage you to continue the work you are doing with the new therapist. Bring this question to them, they will know you better than I do and whether that will be healing for you or just another distraction in your life that you dont need.

Proud of you for sticking with it though friend, great job.

Hello,

I take 911 calls in a large city and as a result frequently deal with people with mental health issues. The most difficult for me to deal with are people with strong delusions. A lot of people we can talk a little bit of reality to and refer to mental health resources.

Some are very insistent that they need the police because a witch has created a clone of them and is trying to take over there life, or some similar situations.

Often times they aren't a threat to themselves or others so police cannot bring them to a hospital. Do you have additional advice on how to speak to these people in a way that may be able to redirect them to mental health resources instead of police?

Hey Few -

First, thanks so much for your work. I know you have so much to do and when you get those calls you pretty quickly realize that the person needs mental health support and there is a limit to how much you can accomplish on the phone.

Brief interventions are difficult with delusions, especially when you don't already have a history with the person. Thank you for being patient with them and comforting, those who live with mental illness are 16x more likely to be harmed by a police officer and we need more steady handed professionals like yourself.

When it comes to directing folks toward resources that can be extremely difficult when they are actively delusional/psychotic/intoxicated. Many states are creating "shrink squads" that can be dispatched to those cases to declutter ambulance and police units and do field triage. Other states have a 211 or 998 hotline for mental health support services.

Honestly sometimes the best thing you can do for a patient in that state is nothing. Being calm, reassuring, giving them a phone number or resource, and then NOT dispatching a unit to them is the kindest thing you can do. Not all police officers can keep their cool with somebody who is actively psychotic.

Hi Jim! I was just wondering how you managed to grow up to be a functional adult and therapist, all while being raised by a bat?

Bats, like all Mammals, are very maternal care care for their young.

I have recently being diagnosed with bipolar type 2 and looking to get back into the dating/relationship scene. Previous partners have been unable or unhelpful in understanding, handling and helping me with my condition.

What advice would you give to me when I feel like I am the problem and would just hurt or disappoint a potential new partner? Thank you for your ama

Hi Trollzahar, great question.

So first, congratulations on getting the support to identify the pattern you were experiencing. Undiagnosed and untreated Bipolar is really difficult to live with, and can cause lots of struggle not only in our own lives but in the lives of people who love us.

Hopefully at this point you are getting access to good medicine tools and good therapy support. If not, that of course is the first thing I want you pursuing.

Second, we've gotten similar questions on the show in the past. Lots of people are unsure if/when they should reveal to people they are dating that they have a mental health history. The stigma and general misunderstanding people have can result in fear or confusion that most folks would just rather avoid.

One thing Id encourage you to do is get good at explaining what Bipolar is. This is one of the most misunderstood diagnoses out there. People think its merely emotional, when it reality it has to do with a "state of mind". However, medication is highly effective at regulating these states and its important that you communicate this as well to people.

In general I am an advocate for sharing your truth when you are ready with people who feel have earned that information. Im sorry you've experienced some partners who dont understand and lack emapthy, but please know there are so many of us out here rooting for you, not judging you, and seeing you as the human you are and not some label on a doctor's chart.

Keep going my friend, over time you'll get good at this. Also, dont forget to look for support groups through your local NAMI chapter, you might find some great resources there!

Why I am so lazy ? I am a quick learner, I like to have succes, but anytime I start something "new" or out of my confort zone I get very lazy about it. For example I know that finishing my language study is gonna help me in my career, I am aware of it, I want to do it but I seem to always do something else or try to find a way to avoid it all together. Is kinda ruining my life right now, I tried all the motivational books, podcast, speeches.. all of that is just nothing.

Thank you in advance. PS: English is not my first language (have mercy on my grammar)

Hello Wood et al!

Procrastination is a problem MANY people face, so you are not alone.

First - I'd suggest organizing projects into phases, and then breaking down those phases into small daily tasks, then turning those tasks into a check list that you physically have to check off. Sometimes organization and atomizing your processes makes a difference.

Second - Its ok to be daunted by big things. You might need to develop a system where you do a task for 40 minutes and then take a 20 minute break. Finding the rhythm that works for you is key.

Third - If you keep noticing in life that you are unable to focus or generally struggling to complete things you might want to talk about this with your doctor. Sometimes people have Attention Deficit Hyperactivity Disorder and there is a medication that can help those people focus and complete tasks.

Good luck!

My husband's mentally abusive mother is dying. How do I help him deal with all his obvious mixed emotions?

Hi Lois -

Im sorry to hear what your family is going through. This situation can be very complicated for your husband, but dont be surprised if he is devasted by losing her despite her being so toxic toward him. We are often deeply attached to our abusers, and her death will effect him.

I would encourage you to be present for him. Encourage him to express all his emotions, even when - especially when - they contradict or dont make actual sense. Dont judge those or try to pacify them. Think of grief as a smoke that is filling the room. Your job is to breath it in on his behalf so there is less for him to have. There is no right way to get through this, but make your presence felt and give him permission to be a mess.

After ward you might encourage him to process all this with a therapist.

Is it appropriate to classify QAnon as a mental health problem in the United States?

No. We need to be careful never to weaponize mental health. The political and legal lexicon has all the words you need to dispute organizations like QAnon, if we sully mental health in attempts to discredit or characterize others we risk losing the credibility of the institution of clinical mental health, which is far too dangerous.

After reading through the first couple of pages, I subbed and look forward to going through your back catalog.

My question popped in my head as I was reading through your most recent episodes, specifically "how dental health effects mental health"; has the opposite been explored as well?

Short background for the question: I had a very traumatic experience as a young child back in the late 70s, being put in 4 point restraints and head forcefully held in place as they drilled out a cavity with no anesthesia (told they couldn't find the nerve with the needle). This was so traumatic I didn't get into a dentist's chair for decades, and when I finally did in my early 40s without being knocked out entirely I had a full-blown panic attack so bad that it took nearly an hour to subside and they almost called an ambulance.

Of course, as you can expect, my teeth now suck and it does effect my mental health as well; I'll be listening to this episode on my way home tonight!

Other than being drugged, do you know of any resources that can help me cope with this paralyzing dental anxiety?

Hey Kodiak - Thanks for being a new listener!

Man I'll tell you reading that story hits home for a lot of people. Obviously your experience sounds horrifying and uniquely traumatic, but for many of us healthcare (and especially dentistry) feel scary because we have had bad experiences. Then we become avoidant (see PTSD symptoms) and our self care goes down the tubes.

I think its entirely appropriate to use medicine to manage the anxiety while you undergo dental care (just make sure the dentist is completely aware of what youre taking and when you took it). Another option - which requires more effort - might be to do a course of EMDR treatment for past trauma. This technique has shown some great results in helping people diminish the fear reaction inside of them to key moments in their history. You should look into that!

What are some issues that you see many people struggle with but due to stigmas of therapy and talking about therapy don't realize are common problems that many people struggle with ?

Depression and anxiety in men is a pretty common one. As a male therapist I often see male patients who have struggled for a long time and often begun self medicating with marijuana or alcohol instead of getting help. Men often don't feel allowed to have mental health problems because the world has no use for weak men. Its a huge barrier to getting them help.

How do people put their mistakes behind them? I can’t help but relive my worst moments over and over. For me, this is further exacerbated by the current culture of public shaming and cancelling of people that screw up.

Oh I totally get this. If they ever invent that red flashy memory eraser from Men In Black I will be the first in line to zap away the parade of failure that blows through my mind every day.

But enough about me.

I will tell you that these types of thoughts, sometimes called Intrusive Thoughts, are difficult. They become worse the more often we focus on them and entertain them - kind of like when you click an add on social media and now you see that same add everywhere - when we click the popup intrusive thought our brain plants a cookie that causes it to come up more often.

You might benefit from reading a book like "Overcoming Unwanted Intrusive Thoughts" by Cloud, or looking into some Trauma treatment with a therapist. There is a technique called Eye Movement Desensitization and Reprocessing that focuses on eliminating the emotional sting of past memory.

Thanks for your willingness to answer questions!

What kind of modalities do you practice?

How often do you find yourself forming a really deep, intimate connection with your clients? Do you find they form an insecure attachment to you? Or it evolves into secure attachment?

How often do you see a client and then they graduate with you, as in they decide they don't need therapy for the time being? They're confident to take on the world.

Do you miss your clients after you no longer see them anymore? Do you have any/a lot of clients who like to write to you once in a while to say hi? Do you like hearing from them?

Hi Naturallog!

Re: Modality - I use Rogerian Person Centered therapy. I tend to have a Solution Focused Brief Therapy approach and I also like CBT for anxiety.

Re: Connection - I form deep connections with my patients all the time. I believe that the key to success lies in us being genuine human beings with one another, and I don't shy away from really bonding with my patients. Sometimes those attachments can be insecure, avoidant or secure, but over time part of the therapeutic process is using our relationship to develop insight into all relationships.

Re: Graduation - All the time! The greatest compliment I get as a therapist is suddenly seeing a 5 star review from a patient who ghosted me months ago. I am thrilled to see them moving forward without me. But Im always there for them if they ever need to check in.

Re: Missing Clients - In a sense yes. I miss them how I missed my students who graduated (I was a highschool teacher for 8 years). But Im always happy that they dont need me anymore. Its a bitter sweet thing.

How do you deal with being numb? I've moved to a new country for work, away from my girlfriend and family and I know I'm supposed to be sad but I'm just numb. What do I do?

Sometimes our brain anesthetizes our pain so we can function effectively. Its not uncommon for people who experienced significant loss or change to suddenly feel detached and numb, which may scare them. But the truth is that numb isn't always bad, sometimes its part of the processing. If it doesnt change in a month examine whether you need to give yourself permission to feel happy again, and not judge yourself for that, but dont be afraid to talk through these feelings as well.

How much will you pay to not have the "missing episode" leaked on reddit?

Name your price you monster

After some months of therapy and some growth, I feel like my inner conflict has gotten more divisive. One side is more easy going and the self care/self talk is a lot more kind and understanding, the other side wants nothing more to embrace what people have said I am, all the bad things I’ve heard, and that I deserve it.

I guess my question is this takes years of work doesn’t it? The healing. And I guess I need more therapy. I’ve setup an appointment with my therapist (who is amazing but I haven’t worked with them in over a year) but I’m worried I’m just wasting my time.

Hi Exotic -

Im really glad to hear you're getting back into therapy and that you enjoy working with your therapist.

Self care is never a waste of time. Leave room for therapy to be the "emotional yoga" of stretching and general maintenance, it doesn't always have to be a formulaic process to find an answer. I hope you will investigate and language your internal conflicts with your therapist, Im sure they will tell you that it is entirely natural to be of two minds on many issues and they will help you develop that healthy inner voice.

Why did the cost of my therapy increase during the pandemic when my therapist was zooming into sessions with me from his home and wasn’t paying for an office space?

Well, I don't feel comfortable defending your therapist in particular. But I will speak to why I raised my rates in my private practice.

First, I still have an office and still pay rent. That rent also went up. Even though I do all my work via zoom, I like having an office in case I ever need it, and it allows me to mentor new therapists.

Second, all my other expenses went up. My calendar app, billing system, medical records service, advertising and communications systems all raised their costs.

Third, inflation and scarcity means I have to pay more money to have a family van for my children, and more for gas, and more for milk, and more in life. I needed to give myself a "raise" to account for all this, which means I had to announce to my patients that I was raising my rates.

Therapists hate talking about money stuff. It feels gross. I wish the system actually worked and therapists were easily paid by insurances and patients didn't have to feel the pain of the cost - but our reality is what it is.

How can you hold people accountable, more specifically narcissistic people?

NPD is a very hard thing to deal with - especially because it mostly effects the people we love more than ourselves.

I did a deep dive on our instagram about how to treat NPD, which you might find interesting: https://www.instagram.com/tv/CTVTX79hdQT/

In the end the best way to hold people accountable to tell them directly how their behavior makes you feel. They may not be able to receive that or have a useful response to it, but that is about all you can do in real life. Sometimes you have to read the relationship carefully and conclude that that person may not have the ability to support or love you as you feel you need, then the boundary of distance may be in order.

Do you recommend Anti Depressants for someone dealing with depression? Or do you look to other alternatives instead? This is all assuming that therapy wouldn't be enough, and that there would need to be medication introduced of some kind.

Hi Corp, great question.

So depression is a REALLY tricky thing to treat. Unlike other disorders, like say Anxiety, Depression doesn't have a pin point cause. You can't ask what "triggered it", it just feels like an entire weather system has settled in over your whole life, and in every direction you see nothing but the grayness of despair. Hopelessness and becoming unmotivated are serious dangers of the disease of depression, and they can make it really hard for patients to benefit even from psychotherapy.

This is why its really common that therapists will recommend you consult with a general doctor or psychiatrist and consider going on anti depressants for a while. We usually suggest this because (1) Anti Depressants are one of the most longitudinally studied medicines in existence and are widely considered safe and (2) Depression can take a turn for the worse and cause significant interruption in work, family, health and overall wellness. Of course its no secret that suicide is something we worry about as well.

For anybody who is dealing with depression, I encourage you to take a Kitchen Sink approach, throw every possible thing at this problem - from therapy to medicine to diet to music to art to sunlight to volunteering to foster a kitten - its not easy to lift this weather from a persons life, but if you stay open minded and willing good things will come =)

I was raised in a religion that taught both sins of COmission (doing something wrong) and sins of Omissiom (neglecting to do something good)—ie that if you weren’t doing all the right things at the right times you were messing up—and the combination of the two plus a lot of other religious nonsense left me with a crazy case of perfectionism. I’ve realized that many days I’d rather sit on the couch and do nothing than try to do something I like and make any mistakes. It’s particularly hard since I’m a writer, a lot of time sitting with anxious thoughts. Any advice for shedding this unhelpful mindset?

Hey Good -

This is a great question because MANY people relate to you.

Im the more faith friendly member of the podcast, and since I come from a similar background I totally get what you're saying here.

I guess the thing I would tell you is that our theology can have a major effect on our psychology. If this is something you spiritually struggle with (fearing that you will fail God by insufficient effort) I encourage you to discuss this with your Pastor/Priest/Imam/Rabbi/etc and ask them to help you understand what your faith teaches in this matter.

If this isn't so much a theological issue, Id bring you back to that old adage about focusing on progress rather than perfection. There was reddit post recently that spoke to this which I enjoyed, it talked about seeing every activity you do in the day as leveling up various abilities you have. Talking to a friend, +1 to social skills. Making a sandwich, +2 to cooking skills. Having that improvement and exploration mindset may help ease the black/white thinking of perfectionism.

If you haven't already also look into Cognitive Behavioral Therapy, there is some great stuff in there on perfectionism.

Peace be with you.

Hey Jim, what's it like having a mom who's a bat? And is Washington or Oregon next to Canada?

Having a bat mom is...confusing.

Also I now have the acronym COW to guide me, so I know that Washington is the top one

Im a 35 year old female. I have borderline personality disorder and last May I had a stroke where they did an MRI that showed multiple legions in both hemispheres of my brain that could signify multiple sclerosis and now I can hardly walk & have multiple other symptoms so I'm pretty sure that I do have multiple sclerosis. My question is, Have you ever treated someone who has both BPD & MS? I have no insurance & I can't work & I live in Texas. I have already applied for disability . Do you have any suggestions for me?

Hi Momo -

First, Im so sorry to hear about these challenges. MS is a condition that doesn't get talked about enough and Im glad you are sharing your story here.

Second, if you haven't already read our blog on how to find a therapist, you should.

Third, Im glad you are applying for disability, and if you haven't already you need to apply for state medical insurance. You should also contact your local chapter of NAMI and see if any support groups exist online for you to attend.

Fourth, yes, I have treated patients who has MS and BPD separately, I dont recall if any had them simultaneously. The good news is that you now have the information you need to identify the treatment options you will most benefit from. You'll probably have to focus on both in separate areas, MS will be more medical, BPD will be more therapeutic, but the two will also overlap in many ways.

Glad you're here friend, thank you for sharing and keep doing the next right thing.

Do you ever get tired of listening to other people's problems and does is ever emotionally strain you? If so, how do you deal with that strain?

Compassion fatigue is a real thing, and something we try to teach new therapists how to deal with and manage.

We've had questions about this exact thing on the show, I'm sure one of the minions will post a link.

But I will tell you that the joy of the work far outweighs the strain. It is not always taxing to hear people's sadness, often its deeply beautiful and rewarding to stand with somebody who is feeling so vulnerable.

I get tired. But not of doing therapy.

How can I fight lonliness when reaching out to friends (or trying to make friends) seems to further isolate me?

Hi Ease -

This is a very real experience. When we reach out to our friends they have no idea how badly we need to be pursued by them, they aren't mind readers and unfortunately they often fail to connect with us as we need them to. We actually had a great question about this recently, you should listen: https://podtherapy.net/post/678953706542235648/219-emotional-affair-socially-paralyzed

Will your podcast be done in full frontal nudity? What a refreshing take on my PG-13 rated podcasts.

We exclusively record naked. Thank god its an audio show.

What is your opinion on the effectiveness of TMS therapy?

Ive had patients try it, some have benefitted from it. The science is sound, its not for everybody but I take a kitchen sink approach to depression so Im for all possible ways to improve the patients life.

Hey I've been listening to your podcast for a while! Thanks for doing an AMA.

I find frequently you all have opinions or perspectives that are very different from mine. Most of the time I really appreciate it because you all put these topics in such a way that I can understand your perspectives, even if I still disagree. Mainly I'm thinking of the episode you discussed Gay Conversion Therapy, has your view changed with the discussions of the 'Don't say gay' bill? I know that episode was pretty far back, have you ever thought about revisiting the topic?

Hey Devac, thanks for listening!

My (Jim) view on Conversion Therapy is basically this:

Its bad. It doesn't work. It does harm. Therapists shouldn't do it because our ethical codes already forbid it. I get itchy when state lawmakers start legislating exactly what therapists can and cannot do, because the therapist (rule followers) already wouldn't do those things and non therapist counselors who were doing those bad things in the first place will just keep doing them anyway since the law was written about therapists and not them.

The "dont say gay" bill represents a really dynamic conversation in our society about influence. Im not sure I have the expertise to speak to it.

Hey guys, I'm looking for some guidance.

I would like to cut back on my reddit porn consumption but I keep coming back for more. Any advice?

Ffyitfydatfowiatf

Salt pork!

So compulsive sexual behavior is a thing, and its something I wish more people would talk about. I would encourage you to grab a workbook on compulsive sex behavior - sometimes referred to as sex addiction - to learn more about how to interrupt and replace the compulsive behavior.

The good news is this gets better, and a lot of people relate.

When do you know it’s a good time to stop therapy? (ideally it could go on forever but it’s also expensive)

Hi Omg -

Great question! So Id suggest you tell your therapist youd like to review your "treatment plan" or goals and discuss what the next chapter looks like. Tell them that at the end of a session and ask that you two discuss it in the next session.

They will probably review with you what you have worked on so far and give you feedback about where they think you've made progress. You can ask what their recommendation is, how often you should be coming in, or if its time to pause therapy altogether. They will give you their clinical recommendation.

Alot of people mistrust therapists in this area, they think we will hold onto the patient forever for the money. We wont. My calendar fills regardless. Ethical clinicians want to see you feel comfortable ending therapy, but we often won't bring it up ourselves because we never want a patient to feel pushed away or abandoned. If you bring it up, we will give you feedback.

Can Jim find any of the three Georgias on a globe?

So I honestly only know of 2, and have no clue where one of them is and the other one is in the south but Im not sure where

I’m interning right now for my masters in counseling, and I had to work at an agency that is staffed entirely by social workers and addictions counselors. My professors are quick to drag social workers and addiction counselors through the mud, saying they don’t know what a mental health counselor knows and therefore my knowledge is superior. This irritates me, as the social worker who hired me is by far the best therapist I’ve ever encountered and the addictions counselors there certainly are getting results.

What do you think of the divide between mental health counselors and social workers?

Hey Doc!

Yea the tribalism between the disciplines is dumb and outdated. Seeing colleagues as less than merely because they trained in different areas is not only inaccurate but robs the team of the benefit of collective wisdom.

In my opinion the disciplines need to unite against the common enemy of the insurance industry and advocate together for systemic change that benefits the patients.

Having said that Im super jelly of Clinical Social Workers because those jerks are allowed to work with Medicare and the Department of Defense.

I feel like maybe I never learned how to deal with real-world issues. I have been dealing with a lot of anxiety. I've been doing worse in my studies and I can't help but feel like I am backsliding on all of the work I have done to better myself over the years.

What are some self-reflection exercises I can try to find direction in life and take action when putting it off seems easier and I often find myself putting my head in my hands and crying all night when the pressure builds and I have to make a decision?

(And yes. I actually scheduled a first appointment with a therapist today)

Hi Asex -

First this is very common. Anxiety is overwhelming and we can feel paralyzed by it, unable to make progress.

Since you're looking for self exercises Id suggest Dr. Aaron Beck's "The Worry and Anxiety Workbook", its a great hands on set of exercises that I think you will find helpful.

Super glad you're seeing a therapist, I think its going to lead in a great direction. Dont be afraid to get started with an anxiety workbook, just tell your therapist what you are working on and they will join into move you along.

are there actual reasons for not killing yourself aside from regular platitudes?

Hi Tova -

Sounds like maybe you are going through a lot.

First, Im glad you're reaching out and Im glad youre here.

Let me try to answer your question without any familiar platitudes like "it gets better" or "never give up" or "you are loved".

Reasons not to kill yourself:

1. Change is inevitable. Depression tells us that we will feel the same despair and stuckness forever, that life is an endless descent into sorrow and there isn't a point to anything. But in reality, the universe and everything in it is changing in every way and at all times. The future that depression tells you exists is a lie, a delusion, and the truth is that your future is unpredictable as your past has been.

2. Here is an interview I did after a Transgender Teenager died by suicide that speaks to the concept above: https://www.youtube.com/watch?v=dEpoTwveoMw&ab\_channel=NikLotusPlays

3. I've lost patients, and it fucking sucks. Listen to this live reflection I posted after losing a patient to suicide: https://www.patreon.com/posts/jims-journal-34636112

4. Survivors of suicide have an important perspective that can't exactly be put into words: https://podtherapy.net/post/649781489012244480/173-surviving-suicide-with-robert-shields

5. The McRib is coming back.

If you need to talk please call or text the suicide hotline 800-273-8255, dont believe the lies of depression, your life is worth living my friend.

Hi, I have anxiety and depression and I started with a new therapist after a break last week. A barrier I find with therapy is that I don't understand the science behind it. I like to know how things work and I find I either get a lot of chat which isn't necessarily backed up by anything, or terms like CBT and ACT thrown in without explanation. How do you address the accessibility of therapeutic techniques and terms in your practice? And how would you suggest I approach this in my therapy sessions?

Bonus question - are you all as bad at geography in real life as you seem to be on the show?

Great podcast guys! So glad you can help Jacob promote the benefits of life coaching!

Hi Hmitian, thanks for being a listener!

This is a really common distraction for folks in therapy, and I get it. We dont always feel comfortable not knowing how the magic trick is done. Sure, we want the outcome, but so much of therapy can feel sort of woo-woo that we'd prefer to know how the sausage gets made.

Basically, all therapy techniques/theories are designed to approach the cognitive (perspective) problem that the patient is struggling with, and assist them in language and altering their perspective to adjust. The science happens when these approaches are tested to see if the presenting problem (anxiety, depression) is diminished more successfully than doing nothing at all or merely offering medicine.

This is why the "science" of psychotherapy can be baffling. Its really more of an art that is subjected to scientific scrutiny. Why do humans change when they experience cathartic release? Are people the sum of their neurochemistry or is neurochemistry the result of who we are? These and many other questions are in that gray area of psychology and neuroscience where we don't have an exact causal description of things. But therapists are trained in the art of psychotherapy to get the medical benefit of mental health change.

This, by the by, is also why the greatest predictor of therapeutic outcomes is the therapist and not the technique.

Re: Geography - No, that entire thing is a masterful ruse. Im actually a genius of geography and I've fooled you simpletons into believing otherwise. Good day sir.

How do you break up with your therapist?

Hi Everton! Great question

We actually answered EXACTLY that question right here: https://podtherapy.net/post/639638396651831296/157-new-year-goalsobjectives-breakup-with

Hi! I (19) was diagnosed with ADHD last year, my psychiatrist put me on Ritalin and they really helped. However my parents hold very traditional beliefs: I live with them so they took my meds away and stopped me from seeing my docs, thinking they don’t work as I’m just lazy, I just need to focus more, other ppl have it worse, the side effects are dangerous etc. I’ve tried explaining to them but to no avail.

Fast forward to now: I’m struggling in med school, from horrid time management, organisation, and an inability to sit down and focus studying for more than 20 mins before I get bored and distracted and start doing something else, seriously affecting my grades.

My question is this: I want to get back on meds, what would you suggest I do and say to my parents? I’m so scared of their overreaction. Also very in need of tips to handle ADHD inattentiveness without meds — got anything for me?

Thank you and I love your podcast!!! Subbed :)

Hi Canucks!

This is a great question, and we have had lots of questions about ADHD over the past couple of years.

Im not sure how we are going to help your parents understand the value of the medication or the reality of ADHD. On one hand I appreciate their concern, the truth is that most mental health issues are exaggerations of otherwise common traits, and ADD/ADHD is very much like that, which is why it is often overdiagnosed and seen with suspicion.

But at the end of the day the medications people use for ADHD is not about treating ADHD, its about treating the symptoms. Ritalin is a performance enhancing medication, and if you are using appropriately then I see no reason you shouldn't have access to it.

Of course, Im not your Dad, and I don't exactly know what would convince them. I wonder if you feel that their opinion must be obeyed in all matters of your health, such as birth control. Are there areas of your life, like your healthcare, that you feel are private only to yourself? Would you feel dishonest or disobedient in partaking in other forms of legitimate healthcare without their permission?

I guess the question you need to wrestle with is where your boundaries are with your parents now that you are an adult who needs to manage their own life. Im not saying this is an easy thing to deal with, but it appears you're going to have to make a choice in suffering with your parents dismay or suffering underachievement in med school.

Is there an origin for pure obsessional ocd intrusive thoughts?

It’s hard to explain to a neuro typical that I have thoughts of cutting off my hand or jumping into traffic but have no desire to do so.

There is a great book on this topic that I highly recommend called "Overcoming Unwanted and Intrusive Thoughts" by Cloud. Great treatment on the topic with advice on how to overcome it.

Also I believe we did a few episodes on that, here is one: https://podtherapy.net/post/190547400298/108-out-of-network-therapy-therapist-friends

Okay, so I have a question and I've never known who (or even how) to ask. Maybe you'll have something for me.

But I've had this thing happen to me at really random times throughout the last few years. It's like my brain sort of briefly disconnects? Everything around me feels both familiar and unfamiliar and I have to reorient my brain.

For example, I'll be talking to my fiancee about our plans for the evening. During the conversation, i will randomly feel like I'm sort of having an out of body experience. My body is there, and my mind is still controlling it, but everything feels extremely unfamiliar and hazy. I remember who my fiancee is, but she still feels unfamiliar somehow and I have to still remind myself of who she is and what she means. And then, BAM, after maybe a 10 second episode, I'm back in my body and everything is totally normal again. If it happens by myself, I still have to reorient myself with whatever's around in a similar fashion.

So...what's happening and should I worry? Should I talk to a doctor? This only ever happens for maybe 10 seconds at a time and the incidents happen maybe 5 times a year so I never really looked for answers.

Hi FruitJuice!

So this is a great question and Im glad somebody on the thread finally brought it up.

Now, I dont diagnose over the internet, but what you're describing sounds like dissociation, a very common thing that all humans do from time to time without realizing it.

Examples: You're driving home at night and suddenly you arrive at your house but barely remember the drive at all. You're watching a show and during a commercial you suddenly forget what you were watching. You read a page in a book and when you get to the end you have no idea what you read. You are talking to somebody and it feels like you are watching yourself have the conversation.

These are all examples of dissociation, depersonalization, and derealization. Those three D's are common experiences among humanity. For some people, those experiences become so common or interfering that we call it "Dissociative Identity Disorder".

From what you're descrbing it sounds like this has been a manageable experience for you. If youd like to do a self assessment you can check out the DES II

I just generally don’t have hope for the future. I feel like we have ~10 years max, and the world as we currently know it will be gone forever. So why exercise? Why save money? I don’t want to have a kid, because what kind of world will I be leaving it to? Don’t really want to fall in love, because then it’ll just be harder when shit hits the fan.

In reality, I am happier with myself and my life than I have been in a very long time. But I just have no hope for a nice future. My parents tell me I need to see someone, but I have seen several therapists and counselors, and I just don’t see a point. Especially with how expensive it is now.

Hey Bob -

Well, I just want to empathize that the world certainly does appear to be 50 shades of garbage.

However, a few thoughts: What if we saw the burning ambers of entire cities ripped apart by nuclear bombs, just after discovering that millions of men, women and children had just been systematically executed by a genocidal maniac? What if half the world was blown to pieces, millions of young men dead and scattered across a continent, and a new global arms race of biological, chemical and nuclear weapons were ramping up?

Of course those were the realities our ancestors faced, not long enough ago in world history. Im sure among them was a person with exactly your fear: this is our world? Why try?

But I imagine if that person came to you and asked if life was worth living, if cities were worth building, if children were worth having, you'd say yes. Even though there would still be Vietnam and MLK, RFK and JFK's assassinations, recessions, terrorism, war after war after war and climate change, you'd probably still tell them that they can live a life worth living.

I imagine the future humans would tell us much the same thing.

I know you don't see the point of seeing a therapist right now, and I get it, but sometimes its healthy to talk through our perspectives. Not merely to see if they should be challenged, but because sometimes just by languaging them we measure them and consider them, if these perspectives will decide your entire life story, you owe it to yourself to consider them professionally.

What do you do if you can't find a therapist when an issue arises, and by the time you can see someone you don't know how to talk about it? I usually have decent mental health 90% of the time, but once or twice a year my anxiety/depression will get out of control. By the time I get in to therapy, I'm usually so removed from the problem that I can't put myself in that headspace enough to talk about it and be production. I do have a therapist but I feel like we usually end up talking about minor annoyances and it's just me venting as opposed to making headway on my goals of lessening/mitigating my anxiety episodes.

Hi Sheshoots -

This is a great question. Its not uncommon for me to have a few patients who only pop into my office a few times a year. Yes, Im their therapist. Yes, I remember them and generally know their big picture story. But just like you they are usually fine 90% of the time and don't feel like they want to talk. But, then that 10% happens and they will pop onto my calendar.

Id suggest finding a therapist that you have worked with and just tell them up front that you are more of an episodic patient. If they are using your insurance they will let you know if there are any restrictions on episodic care, but if you aren't using insurance it shouldnt be a problem. Just make sure you get the therapists direct contact info in case they leave that clinic in the future. You might want to search for somebody in private practice.

Hey, thanks for doing this. My SO (41m) and I (40f) want children. We’ve had 5 miscarriages in the last 3 years.

I‘m trying to find a healthy balance between doing everything necessary that might result in me falling pregnant (pushing for certain tests, getting healthier, finding the reasons why it‘s not happening) and not stressing about it because stress is a cause.

How does one find that balance? I also don‘t want us to lose our joy in the bedroom but I do need him to step up and do the deed on the fertile days even if he‘s tired and stressed from work.

At times I worry I‘m not dedicated enough and then I think I should be more relaxed so that it‘ll happen. Either way I really want us to maintain our happy relationship.

Any advice?

Hi Reise -

This is a really great question and I encourage you to also submit to our show as I'd like to discuss it more in depth.

First, I cannot tell you how sorry I am to read about your miscarriages. I've experienced that myself, and it was devastating. To have gone through this five times is unimaginable, and my heart is with you.

Second, I know that fertility investigation and treatment can be daunting. Its a very unsexy and expensive process and I know how stressful it can be. I won't offer any guidance with that because you have specialists helping you, but I appreciate how difficult that can be.

Third, it is very common for couples attempting to conceive to struggle in the bedroom. Sex feels mechanical, and the joyful emotion is replaced by fear and high pressure. It can be hard to recapture that energy. One suggestion Id make it to get a date box - there are many companies out there offering all sorts of things from PG to XXX - but it could be something you could plan on using on a night when you are expecting to be fertile. This might help things feel more organic while also having the benefit of being organized.

Also, hey Date Box companies, give our podcast money and sponsor the show Id like to tell more people about your stuff.

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Hi Phil -

I don't care that you're on benzos. But if you are slamming them like skittles I care.

Partly because it tells me your symptoms are managed very poorly and we need more tools. Partly because benzos should increase - not decrease - a patient's functioning and if they are doing the latter its a problem.

And yes, partly because they are highly addictive and we have a responsibility to do no harm. We aren't so much afraid of being sued since therapists don't prescribe medication, but we do have a responsibility to monitor you.

Hang in there Phil, great question.

I'm worried about my mom. She tells me about her boyfriend being a narcissist and gaslighting her. I know these words are overused, but this is how she describes it. Based on my interactions with him for the 10 years they've been together and her stories she tells me on the phone, at the very least, he's not a good partner. She's not perfect either, she's had explosive moments (even some violence) that should have ended the relationship, but they keep staying together.

Whether he's a narcissistic gaslighter or not, I've told her time and time again to go to therapy. At the very least, for herself, but ideally couples therapy. Every time she talks to me about him, my advice is always the same. But she won't go.

Any advice on what else I can do to help?

Thanks for doing this AMA, a lot of the answers have been great so far!

Hi Oh no -

This challenges comes up often. How do get somebody we love to go see a therapist and work on the problem rather than just repeating a toxic cycle?

Well, part of the answer is exactly what you've already done. Advocating, educating, maybe even passing our blog along so she knows how to find a therapist.

The other part could actually be her use of words like narcissist and gaslighting. Sometimes what brings people to therapy is seeking the validation of the pet diagnosis they already came to - which is totally fine. You could always take the road of "Mom, you might be right, he might really have NPD. You know, you should really go see a couples therapist and see if they can diagnose him, maybe then he'd take it seriously".

The therapist will know what to do with that. I've had many patients come to me to verify a diagnosis. I usually know how to gently earn their interest in meaningful change rather than name calling.

Thanks for caring and being an advocate!

Why are so many therapists unwilling to consider the possibility of undiagnosed adhd and/or autism? Why are so many people begging for help and not getting the information they need on their neurology to inform the therapy and perspectives? What needs to happen to create a more understanding and collaborative space for ND informed mental health support? How do you find that support in the current climate?

Hi Obiwan, may for the force be with you -

Re: Undiagnosed ADHD/Autism - These are hard to diagnose because the are an exaggeration of otherwise typical human patterns. Many patients are influenced (rightly or wrongly) by Tik Tok and Instagram trends and come into therapy with a case in hand for why they believe they have a diagnosis. This, in general, is not how diagnosis works. But ADHD/ASD in particular are nuanced and difficult just because they are. Most therapists will refer a patient to a specialist to receive ADHD/ASD diagnosis. But in America, you really don't need an ADHD diagnosis to begin ADHD medicine, your local Psychiatrist will be happy to get you started and probably won't even really ask about you symptoms.

Re: Neurology - Im not sure what you mean. Neurobiology is a frustratingly unclear science. I wish it were as simple as putting people through a scanner and then knowing exactly what they need or what medicines will work for them. Unfortunately there are a lot of neuro-snake-oil-salesman out there hawking all sorts of non treatments as if it is "cutting edge" science that "the mental health professionals dont want you to know about"

Re: Neurodiversity - So the tricky thing about being "neurodivergent" informed is that, again, we are talking about exaggerations of common patterns. So on one hand you want mental health providers to not see ADHD/ASD as terribly distinct from the rest of the population because you want the conditions normalized and not segregated into this us/them identity things (which is happening in social media). On the other hand we want therapists to be educated on what helps those who have these conditions be successful. Generally speaking I find that my ADHD/ASD patients benefit most from support groups rather than therapy. They thrive on information and education, finding out how similar people manage their lives. Im not always their greatest resource.

How do you detox at the end of the day? I would imagine as a lightning rod for everyone's feelings and bullshit, you guys have to have your own coping mechanisms in order to continue to do what you do.

Wondering if I can take some of those lessons/practices and apply them myself.

Also wondering if you see people and just roll your eyes. Like "I make 800k a year and my family is perfect and my car always starts and I have a beautiful home and just climbed Everest, but I'm sad." Wrestling with a bit of that myself lately, where I've walked the path and done everything you're supposed to, and have all the trappings of an upper-middle class life (I even had the white picket fence installed last Fall). But I'm fucking miserable. And I feel like bitching about that to anyone will just get me laughed out of the office.

Hi Ruck -

Re: Detoxing - This is a great question. Different therapists have different ways. Most therapists do paperwork at the end of the day, which sort of allows them to detach and release things that happened, even though they are writing about it. For me its podcasts. I love going through my queue and learning about space or magic or listening to the nonsense of my favorite comedic personalities. Sometimes the best way to detox is to palate cleanse with new flavors, finding a stark contrast to the mentality you've been in to reboot you for what comes next.

Re: Champagne Problems - So Im a private practice therapist in Las Vegas, and I've treated my fair share of world famous entertainers, professional athletes or otherwise successful folks. I can tell you that while money solves many problems it does not solve the fundamental realities of existence. All humans suffer, all humans struggle. One of the things Im actually quite proud of as a therapist is that I appreciate the unique realities some of those "well off" people face, and I don't see their problems as less than or illegitimate, just unique. Don't feel ashamed to "bitch" about your life Ruck, sometimes we need to do that sort of emotional inventory to rediscover what we love about our lives.

What do you think of people claiming to be their friends' "therapist"?

They probably mean well. Actually, that kind of person is exactly who I hope will consider going to grad school and becoming a therapist. The best therapists were sort of already doing the job anyway, lol.

As therapists, what are your qualifications?

First, we are really really really...really really ridiculously good looking.

Second, most therapists have a bachelors degree and a clinical Masters degree (60-70 credits), they practice as students for a year and then practice as an intern for 2-3 years post graduation, during that internship they are supervised weekly by 1-2 veteran therapists who oversee their work and coach them, then they pass at least one national exam, pass their oral boards with the state, and are finally made a full fledged therapist.

Overall to become a therapist will require 7 to 8 years of school plus 3 to 4 more years post graduate training.

Hey Pod Therapy guys, thanks so much for the podcast. I really look forward to your episodes and enjoy the community you have created.

My question relates to eating disorders, specially how you know when they're a problem. I was diagnosed with atypical anorexia, but it's hard for me to take it seriously since my BMI is still normal (on the border of underweight). I don't feel like I'm restricting intentionally and am not "terrified of gaining weight", although I do prefer to weigh less and sometimes eat less than I probably should, mostly due to stress. I have some medical issues that are related to having too low of a caloric intake, but other doctors in the past have concluded that caloric intake isn't really the main issue. I guess I'm just struggling to motivate myself to eat, and honestly focusing on the diagnosis has made me want to eat less not more. Any suggestions for me? Thanks for all you do!

Hi Astronaut! Thanks for listening!

So I'm reluctant to speak to the diagnosis or symptoms because obviously I haven't assessed you.

However, I will say that many people with Atypical Anorexia feel similarly as you. Those key indicates of health outcomes, BMI and weight can feel detached and impersonal. They often wonder whether their situation is sub-clinical and perhaps things need to be measured in a more personal way.

For me, the most important thing I want to learn about in a person's life is the distress they experience as a result of the behavior. You appear to have a list of "harms" that come as a result of low food intake, but I totally understand why the label of Anorexia can cause you to feel confused about all this in general and actually inhibit your appetite.

If you aren't already talking about this with a therapist, I would strongly encourage it. What your describing has everything to do with perspective and emotion rather than education or habit. That is exactly where a therapist wants to help. You might also want to consider support groups where you can get perspective and share your feelings with others who completely relate. We had an episode on this exact topic actually, one of our minions should be able to link to it.

How can I support a loved one who desperately needs help with their mental health, when those same mental health problems make them suspicious and distrustful of therapists and doctors? They have verbally abused and alienated everyone who has tried to work with them so far. I'm at a complete loss.

Hi Floothekoopa -

So this is a tough one, as you know. When a person is unwilling to get help and keeps sabotaging their treatment it can be really hard to break through and make a change. Especially if they are above the threshold to be involuntarily held, there is little you can do to get them into care.

My advice would be to see if they are willing to start small. Maybe with a NAMI support group, or the therapy programs that offer texting or short 30 minute encounters. If you can get this person to just take the smallest of steps in the right direction that can lead to good things. Even buying a self help book and offering to discuss it with them weekly, or getting them involved in a mental health supportive community. Any small step can lead to bigger things, but I realize how powerless we can feel to help somebody who refuses to be helped.

Sometimes we also - and this is very hard to hear - need to be willing to offer people the dignity of discomfort. Pain is our greatest teacher. When people hurt, they sometimes become willing to get help.

Thank you for caring so much my friend, please remember to care for yourself as well.

My best friend (F 40s) has such a big heart. She lets these men into her life who just destroy her in a matter of weeks. How can I help someone who self-sabotages, and everyone else can see it, but also encourage her and be there for her without ‘I told you so’ type discussions?

Hi!

We had someone write in with a very similar question sometime this past year and we answered it on the show. I've been trying to find the episode number, but have had no luck. If any of our listeners find this, maybe they can help with that.

In the meantime, some advice I'd give you is to be patient and do your best to try to understand that this is not a conscious chose that is being made, but subconscious. We see patterns like this often with adults who were in abusive environments when they were children. I don't mean to imply that that represents your friend, but want to use this as an example to illustrate my larger point.

As children, our parents are our protector and we form bonds and trust them. This also forms the basis for how we evaluate relationships as an adult. When your protector is also your abuser, it becomes very difficult to be able to recognize those traits in others. This is my larger point. It is likely that your friend really struggles to pick up on some of the red flags and warning signs of unhealthy people (for whatever reason).

Be patient, and be a support for her. Express your concerns about people you meet and do so from a place of love and compassion. She will need to learn how to identify these traits in others, that may mean talking to a professional. Do your best to remind yourself that although it seems natural to you, it was something you learned at a very young age, that she did not, and will need to learn it as an adult.

Hope that helps,

What are your thoughts on drugs prescribed for mental health issues?

I personally see a lot of people around me being prescribed drugs, while it can sometimes make people feel better, a lot of them have negative side effects and don't address the root of the problem. I feel there's more value in them seeking regular therapy sessions and working through your mental issues.

Medicines are an important tool in the mental healthcare kit. I like them because they are the easiest to access and for many people the problem is manageable or stops entirely with the right medication.

However, you're right that therapy generally out performs medicine inpatient outcomes (depending on the diagnosis). And the gold standard is a good therapist and good doctor.

Hey guys! So glad to see you doing this again! I am an introverted extrovert. I’ll pipe up in most conversations, but don’t really have outside activities and any that I have had, I find it hard to make lasting friends. My three “real life” friends are basically from high school or my early 20’s There aren’t really any activity groups locally that interest me. I have an amazingly supportive friend group on a Facebook page for a podcast I listen to but those people are all over the world. Do you have some advice on how to “ask” someone to be your friend? Loved seeing you in Vegas and virtual hugs to you both! Tess

Hi Tess!

So many people made online friends during the covid years and are not having to reexplore the whole human interaction thing.

Im a big fan of using meetup.com (sponsor the show meetup) and finding real life people in your area that you can get to know. From there I think the recipe for building friendship is just proximity, the people we have the largest word economy with and most physical presence with just become our friends.

Take me for example, for 5 years I sit with Nick and Jacob every week and against every ounce of their will power I have become their friend. I did try to make them friendship bracelets but both claim to have lost them, so I might not be a great source of advice on how to ask people to be your friend.

FYITF, Jim

What I’ve learned (on Reddit actually) is that it’s not normal to think about suicide constantly. I’m middle-aged and I’ve been dealing with it since I was a young teen. I did try therapy before, but couldn’t emote and just chatted casually for an hour each day. Many years ago I decided to follow through with my urges, but then something strange happened. Deciding to end it was very liberating. I gave up my business, gave away everything, and moved to an island. I’m generally happy, but the suicidal thoughts still persist. I guess what I’m wondering is, how common are these thoughts and at which point should I seek treatment? A little aside I’d like to add is about a year ago I felt severe depression coming on. I could literally feel it getting stronger and stronger over the course of about 6 hours. It was the worst depression I’ve ever had. It lasted about 8 hours and then I felt it begin to fade and after about 4 hours it was completely gone. There was no trigger and I was in a pretty good mental state at the time. This was the first time I’ve felt it come and go so distinctly. If you had to guess, would you say this is a physical or mental issue?

Hi GDJ -

I want to start by saying I'm glad you're still here. When you have faced death itself - either by suicidal ideation or perhaps a scary medical diagnosis or circumstances like Ukraine - it fundamentally changes your perspectives in life. You question everything: your job, your location, your daily reality, and you become willing to see it all change. Fearlessness.

That is what Dr. Frankl describes in his book "Mans Search for Meaning", and you appear to relate to those same conclusions.

I'll tell you that the highly acute emotional fleury you experienced is interesting. Depression is usually defined as a pattern lasting months and months, but this acute and severe onset you experienced might be more physical. If you haven't already done regular blood work with your doctor, I would encourage you to stay on top of that. Sometimes the experience you're describing can be hormone or organ related (see thyroid). Sometimes its nothing. Either way, good self care involves regular check ups.

As far as when somebody should seek treatment for suicidal thinking, I refer you to the baseball diamond of suicide. First base is just thoughts, they are really specific and they aren't exactly practical, we just sometimes think "maybe I shouldn't be alive" or "maybe I could just end it all today". Second base is when those thoughts become more practical. "Here's how specifically I would end my life", "These tools are around me and I guess I would use them if I wanted to". Third base is when we start making a plan. "This day, this time, this method" Rounding third base and heading toward home is when we are preparing to act.

I want to see people getting to a therapist when they find themselves with a lead off of first base. That doesn't mean they are in danger, we aren't going to put them in a hospital, but we want to start talking about it with them and make sure nothing grows.

Thanks for the question friend, hope you continue to enjoy your island.

My recently ex-girlfriend suffers from a severe anxiety disorder. We recently were coming up on moving in together (we were long distance for 4 years) when she changed her mind about moving with me and wanted me to move up near her so that she wouldn't have to leave her family. However before she really gave me time to process reshaping my life, she broke up with me in an email and deleted me from all social media plus changed her number. Another important factor is that she started to see her old psychologist who she saw during a previous abusive relationship; I don't have any real information but I suspect in some way the psych had involvement at least in leading her thought process into cutting me out like this because her email was extremely clinical and didn't sound like her (and as I said I was with her for 4 years).

My question is how do I reach someone who acts like this at an emotional level who is doing something so self-destructive? I know it sounds like I must be leaving information out but it truly was such a drastic move with no real logical basis. I know that I was good to her and that this is a huge mistake but her family system will never confront her on this because she's so sensitive and she has essentially created a fake reality where she doesn't have to acknowledge the action itself by deleting me everywhere. For the record I would totally move up there for her but I needed time to consider moving my whole life. I also acknowledge that if she's removing me from everything, the step may unfortunately be that the ball is in her court and I can do nothing at all.

My follow-up question is then how do I find closure from something like this? I myself have my share of depression and mental illness and having someone who was my best friend/girlfriend literally cut me out of her life like this over virtually nothing has essentially changed my whole world view. I've heard some of the cliches about working on myself but there's not much to learn from the experience because the relationship was great until it wasn't this past month and my one fault was needing time to consider an important decision that would have affected both of our lives fiscally down the line. I can add more details if needed.

Hi Albert -

First, Im sorry to hear about this breakup man. Sounds like this came out of the blue and one minute you're thinking you're about to take a huge next step in your relationship and the next you ghosted in every possible way. The shock alone is staggering.

Second, I think you had a great answer to your own question about how to reach somebody who is thinking as she is. At the end of the day whatever her emotional or anxious reality, she is an adult who can make her own - even self destructive and selfish - choices. The consequence for that in life is we miss out on good people who desired to be kind to us, no matter how much we may insulate ourselves from the pain of our choices in the end there will be no escape from the reality of what we are doing. I doubt there is anything you can do to reach her or change her mind, and Im not sure you should be the one to do any of that, her choices wounded you deeply and I think you have the right to not pursue her now, even if you still love her.

Third, closure is something that can only come with time. Being ghosted like this is a special kind of madness. We are left starting at the wreckage of what has been left behind like a crime scene, trying to piece together WTF just happened. I doubt anybody can stop your brain from playing detective for a while. In time, you will also start to see the larger story of your life, you will experience friends and family and coworkers and you will start to heal from this. But its also likely to leave a scar on your psyche. You may find you struggle with abandonment fears in future relationships. Over time you might want to visit with a therapist and talk this out, I worry you are still struggling with self blame for not immediately agreeing to her abrupt plan change, when in reality your response was mature and responsible.

Make sure to keep your self care up Al, what happened to you was significant, you're allowed to mourn that.

One of the most common things I get asked when I start with a new therapist is "what are your goals for therapy," and I never have a good answer. Like there's a lot wrong, with the world, society, me personally and my past and current, but it's extremely hard to put down a concrete goal or goals. Do you have any advice for that?

And a second question, how would you feel about a new patient coming in with an "about me" pamphlet? Because there's lots of background info about me that therapists need to know if they're going to help, but it really isn't what I want to focus on for the first few sessions.

Hi Toka -

Re: Goals - Imagine that tomorrow morning you wake up and there is an angelic being standing at the foot of your bed. The Angel tells you that while you slept a miracle happened, and you have been changed for the better. The Angel disappears and you get up to start living your day. What differences would you notice in your life which would confirm that the Angel was telling the truth? Your answers are your goals.

Re: About Me - This is adorable and I sincerely hope this happens to me some day. Id prefer a power point.

Does online therapy work? I wonder if I should give it a try, but then it might be the same company running a call center for Best Buy.

Hi Mfo -

YES! Online therapy is - for many people - indistinguishable from couch therapy. The outcomes are just as good, and in my experience I've considered it just as if not more personal than in office.

Sure, there are those big box companies (whose names I will not say until they sponsor my show) and if that is convenient for you I say go for it. But dont forget to look around locally through Psychology Today, Yelp or just Google and see if therapists in your area are offering online telehealth (many now do).

Before the pandemic I think less than 3% of therapists offered online therapy, now more than 70% do, its a huge benefit and I strongly encourage you to take advantage! It also allows people who live all over the nation to find a therapist in a different area - though sometimes this can be a little tricky for legal reasons.

Anyway, there ya go! Now no excuses, get your ass into therapy!

I just had a visit to the ER because of an episode I had the other night. I was shaking violently, felt discomfort in my chest, and it was relatively hard to breathe. After some tests, They told me it was likely Anxiety related.

So my question is this.. can anxiety cause chest discomfort lasting for longer than a day, even when I’m not really feeling anxious?

Hi Hallow -

So the short answer is that yes, anxiety symptoms can mimic cardiac distress. Cardiologists are one of the biggest referrers to therapists because after they clear the physical symptoms of the patient the next best hypothesis is stress and anxiety.

One of the bedeviling things about anxiety is that it can feedback on itself. We have some chest pain, we panic about that fearing its a heart attack, the anxiety alarm system goes off inside of us creating more chest pain, now we feel that and are convinced we are in danger, and round n round the wheel goes.

I encourage you to get some Cognitive Behavioral Therapy training to learn how to interrupt a anxiety spiral, regardless of what the specific cause of your chest pain is, you'll benefit.

Thanks for doing this. I wonder how common thanatophobia is, and whether anything can trigger it, and if I do have it, how should I deal with it?

Hi Will -

Great questions. For those that don't know, Thanatophobia is the fear of death, and its actually VERY common.

Usually it isn't labeled that way because we typically just diagnose Generalized Anxiety Disorder.

Treating it involves using Cognitive Behavioral Therapy, if you cannot get to a therapist I would advise you to pick up Dr. Aaron Beck's "The Anxiety and Worry Workbook", it will teach you about Cognitive Distortions and how to right size the realities of danger.

But Ive had patients that struggle with the inevitability of death. Usually we will suggest Dr. Viktor Frankl's "Mans Search for Meaning" as he discusses surviving the Holocaust and facing the inevitability of death, but some patients say that book felt a little too philosophical for them and didn't exactly help. Figured Id mention it anyway.

My last patient with this particular phobia really benefitted from using externalizing techniques, which involved giving that voice of fear a name and an identity and coming to hear its thoughts as distinct from our own. I believe she named her fear "Clocky" because it was always counting down the days until death. That actually really helped her.

Is it possibile that a diagnosis of autism can be incorrect? Specially for toddlers? If so who is competent enough to review the diagnosis?

Hi Neutral -

Great question. Autism is a very nuanced diagnosis and I prefer patients only be diagnosed by a Clinical Psychologist who specializes in Autism Spectrum Disorder.

Children are especially difficult to diagnose and treat, and if possible Id contact your local school district and ask for referrals to a education specialist. School districts must have resources to diagnose autism and often have provider lists for children.

Advice for me I have anxty, social anxiety & depression what sold I do? I no have anergy, always anxty

Hi friend!

Depression can often lead to low energy and low motivation. Anxiety on top of that can make it hard to get help and start looking for the tools we need to solve it.

Id encourage you to start with bringing this up to your regular doctor, they may recommend therapy or they might offer to start you on a low dose medicine that could at least make it a fair fight to deal with these issues.

From there I would encourage you to look into The Worry and Anxiety Workbook by Aaron Beck, I think thats a great text for tackling anxiety.

What's your opinion on the AH/JD court case?

Boy that is a circus. A few hot takes since we dont have enough of those on the internet:

1. Im glad we are talking about domestic abuse and how complex it often is. While both parties appear to have been abusers, I think its significant that the public is discovering their favorite swashbuckling pirate was hurt by his wife. Men are the largest recipients of domestic violence, but it is rarely reported because men feel they deserve it or that its unmanly to talk about it. I have had many men over the years who are abused by their male or female partners and they refuse to report it.

2. It was strange listening to the therapist testify. I was embarrassed that she didn't have a professional record of the sessions, and I felt she overshared which probably didn't give viewers confidence that therapists are private and confidential. Its very rare that therapists will participate in court proceedings unless ordered to, I was disappointed that she did.

3. The poop in the bed thing was weird.

How to deal with social anxiety?

You'll stop worrying about what others think of you when you realize how seldom they do.

Hey guys, when are you implementing the system where you read time sensitive questions first?

We are mostly just refreshing the page and answering from top to bottom. But we do have minions who are scouring the thread and providing resources to those who might need some time sensitive support.