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Category: Mental Health

How To Choose a Good Psychotherapist

By Deborah Serani, Psy.D.

It is a difficult, yet brave and courageous moment when someone makes the decision to pursue mental health therapy. But more difficult than the decision to go to therapy is the decision of who to go to for therapy.

So, how does someone find a good therapist?

Types of Therapists
First, it is important to think about the type of therapist you think is best for your presenting symptoms and issues. There are many kinds of mental health therapists, but sometimes understanding “who does what” can be confusing. Here is a list to help identify the specialties and degrees therapists can hold.

Psychologists
In the United States, Doctors of Philosophy (Ph.D.), Doctors of Psychology (Psy.D.), or Doctors of Education (Ed.D.) must complete at least four years of post graduate school, however, only those who have been licensed can call themselves Psychologists. Licensed practicing psychologists are specifically trained in the mind and behavior as well as diagnosis, assessment and treatment of mental, emotional, and behavioral disorders. The treatment provided is “talk therapy”. It is important to know that not all psychologists are experienced therapists. Some specialize in areas such as statistical research or industrial psychology, and may have little experience treating people. Therefore, it is important to inquire about the caliber of clinical experiences. Psychologists do not prescribe medication.

Social Workers
Clinical Social Workers (C.S.W.) usually have earned at least a Masters’ Degree, which is two years of graduate school, and some Social Workers obtain a doctoral degree (D.S.W.) . Clinical Social Workers credentials may vary by state, but these are the most common: B.S.W. (Bachelor’s of Social Work), M.S.W. (Master’s of Social Work), A.C.S.W. (Academy of Certified Social Workers), or D.C.S.W. (Diplomate of Clinical Social Work). Although there are exceptions, most licensed clinical social workers generally have an “L” in front of their degree (L.C.S.W.) communicating that they are a Licensed Clinical Social Worker. Clinical Social Workers also receive training in the prevention, diagnosis, and treatment of mental, behavioral, and emotional disorders. Their goal is to enhance and maintain physical, psychological, and social functioning in who they treat.

Psychiatrists
A Psychiatrist completes a medical degree (M.D.) like any other physician, followed by a four-year psychiatry specialty. Psychiatrists prescribe medication yet sometimes do psychotherapy with patients. Psychiatrists, unlike Psychologists, have the background and experience to understand how the body and the mind as a whole react when psychiatric medication is given, and have extensively studied the total body including brain biochemistry, tissues, glands, and organs, leading to a fundamental understanding of how these all interact and react to the patient’s environment in mental health and mental illness.

Marriage Family Therapists & Professional Counselors
Licensed Marriage and Family Therapists (L.M.F.T.), and Professional Counselors (L.P.C.) usually have two years of graduate school and have earned at least a Masters’ Degree such as: M.A. (Master of Arts), M.S. (Master of Science) or M.Ed. (Master of Education). Marriage and Family Therapists have additional specialized training in the area of family therapy.

Certified Counselors
Certified Counselors are typically trained in drug or alcohol abuse specialties. A Certified Addiction Counselor (C.A.C.) or a Certified Alcohol Counselor, (C.A.C.) may have a I, II, or III added to their degree signifying the level of training in counseling (CAC-I, for example). A C.A.C. Counselor may or may not have a master’s degree. Counselors are trained for supportive therapy. C.A.C’s work within the field of alcoholism and substance abuse, providing education, consultation, counseling, aftercare, recovery and advocacy.

Religious/Theology/Pastoral Counselors
These are counselors who are clergy, pastors or who have a Master of Divinity (M.Div.) degree, or a Doctorate in Theology (Th.D.) from a seminary or rabbinical school, with additional training in therapy. These spiritual counselors are trained in both psychology and theology and thus can address psychological, religious and spiritual issues.

Counseling Nurses
Psychiatric Nurses and Nurse Practitioners comprise a growing segment of mental health treatment professionals. They display the credentials R.N. (Registered Nurse), R.N.P. (Registered Nurse Practitioner) or M.S.N. (Masters of Science in Nursing). A Psychiatric Nurse is a registered nurse with a master’s degree who has been trained in individual, group, and/or family psychotherapy. The Psychiatric Nurse and the Nurse Practitioner view individuals from a holistic perspective, taking into account both physical and mental health needs while focusing on human behavior.

Word of Mouth To Yellow Pages
Now that you know the kind of therapists with which you wish to work, how do you choose one?Here are a few ways that can provide leads to a good therapist.

Word of mouth: Asking a friend or relative that you trust can be a great way of finding a reliable therapist. When a clinician is highly regarded, there is usually a buzz in the community about him or her.

Professional Referrals: Contacting your general physician, or inquiring with school guidance and special service staff if you are looking for someone to work with your child are good ideas. Contacting local psychological, psychiatric or counseling organizations can be very helpful in pointing you in a direction as well.

Insurance Company: If you have an insurance company, another suggestion is to call them directly and ask them to give you a few names of therapists in your area, and ones that specialize in the disorders or issues with which you are experiencing.

Church or Temple: Many churches and temples have outreach programs where the person in charge can help you find a therapist.

Yellow Pages: Many times I get calls from people who look me up in the Yellow Pages. With nowhere else to turn, people cold-call with the hopes of finding a good therapist. This experience can be frustrating and may lead you down a bumpy road of contacting therapists who do not specialize in what you need. If possible, try one of the other strategies listed above to help you find a good therapist.

The Initial Phone Call
Once you have a few names, find the time to call each one and talk on the phone with him or her. You can get a great feel for a professional during this informal chat. If you make a connection on the phone, arrange for an appointment to consult with the therapist. I call this “the meet and greet” consult where I get to meet the potential patient, assess the symptoms and issues and make sure that my training and expertise are appropriate for the necessary treatment. This is a time where the potential patient gets to know me as well, how I will work and also learns about my approach to treatment and the parameters of therapy. Though comfort and connection are necessary factors, so too are making sure that the therapist of your choice is educated, seasoned and a specialist in what you are seeking.

Questions to Ask:Most therapists will welcome the opportunity to answer any questions that you may have. Here are some of the most important ones to consider:

1. What is your professional training and degree?

2. How much specialized training and experience have you had with what I am seeking help for?

3. What theoretical school of thought do you follow?

4. How long are the sessions?

5. What is the cost of each session?

5. How does insurance work with mental health therapy?

6. What is your policy on cancelled appointments?

7. Have you been in therapy yourself? If so, how long?

8. Is it possible to reach you after hours in the event of an emergency or crisis? If so, how?

9. Do you receive regular supervision on your cases or belong to a peer supervision group?

10. What professional organizations do you belong to?

Good Therapy
Once these bases are all covered, and you settle into treatment, you should slowly begin to feel an expansion within yourself. Your awareness will widen, your feelings may swell, and you may find yourself thinking in new ways about your situations and experiences in life. Therapy may be tough on occasions, but in time, you should start learning techniques to help change, shift or remedy symptoms. That is how the arc of good therapy progresses. Last, but not least, always, ALWAYS, be sure that the professional you choose to work with is a licensed mental health practitioner

Why Smokers Do and Don’t Quit Smoking

My father-in-law is in his 70s and still smokes every day. He’s tried to quit before, but in the recent years has decided that he was old enough to live his life however he wanted, and that included smoking. Nevermind the fact that he has had a quadruple bypass operation for his clogged arteries (and other coronary operations), is on polypharmacy, leads a sedentary lifestyle, and has been nagged by his doctors and us about quitting smoking for years.

I know that many doctors – especially internists and general practitioners/family doctors – often encourage their smoking patients to quit smoking, citing the harms of smoking and the benefits of not smoking relative to the patient’s capacity to heal. Even those of us who do not practice medicine but work in the healthcare field know that smoking wreaks havoc on a variety of bodily functions right down to the molecular level.

Earlier this year, three Greek researchers published a study on why smokers quit or don’t quit smoking in Harm Reduction Journal (source: Harm Reduction Journal, March 29, 2006, 3:13 doi:10.1186/1477-7517-3-13). What they found may give some insight not just to medical doctors with an interest to helping their patients quit smoking, but for those of us with a personal interest to help either our loved ones or ourselves to quit smoking.

A popular assumption many doctors have about smokers quitting smoking is to introduce cognitive dissonance – an emotional state of mind where two beliefs are in conflict with each other. A person experiencing cognitive dissonance will move to resolve that conflict of belief. If a smoker believes that smoking is harmful to one’s health yet continues to smoke, the smoker experiences this contradiction and would move to resolve that contradiction. One would assume that the smoker would then stop smoking – right?

I doubt that smokers would deny the harmful effects of smoking. We can see from what’s happening in society that this is not the case – people still smoke even when they’ve been exposed to anti-smoking campaigns, nagging from friends and loved ones (I admit, I am one of those annoying people who remind their friends that smoking is bad for them), and shock-and-awe pictures of lungs blackened by chronic smoking.

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How Work-Life Imbalance Makes You Sick

Dr. Sheldon Cohen‘s keynote presentation at the 8th International Congress of Behavioral Medicine was published in International Journal of Behavioral Medicine (2005 Vol 12 No 3, 123-131).

Cohen summarized 20 years of research on psychosocial influences on infection susceptibility.

Cohen also debunks these pervasive myths of stress and disease:

  • Myth: Infectious disease-causing agents is wholly responsible for causing infectious disease.
  • Myth: Stress suppresses the immune system, which makes us susceptible to infections and disease.
  • Myth: Stress overstimulates cortisol production, which leads to susceptibility to disease.

According to Cohen’s article, infectious disease-causing agents are not sufficient causative agents for disease. Our immune system’s modulating responses against viruses in our body determine whether we become infected.

We would also assume that health-related behaviors like smoking, alcohol consumption, sleep, exercise, and diet contributed to disease susceptibility. Cohen has observed that these behaviors were independent of susceptibility to the common cold across five different strains of viruses (including 3 rhinovirus types).

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Truth is More Than Just One Side of the Story

This morning two newsfeeds came to my attention. One came from an open letter from Mental Health America, a non-profit organization. Mental Health America stated its agreement with the FDA not the extend the black box warning label of suicidal ideation risk across all age groups (not just children and teens) to antidepressants after recognizing that antidepressant use may actually lower suicide ideation in elderly adults.

Mental Health America then stated its disappointment with the FDA for extending the black box warning label of suicidal ideation risk of antidepressant use to age 25. The organization’s position is that 90% of suicides occur from untreated or undertreated depression. This extended warning label may discourage treatment in individuals suffering from depression and mental illnesses who may benefit from antidepressants. (more…)

Suicide and SSRI When Medical Legal Risk is High

By Robert Lamberts, M.D.

I had a tough situation in the office yesterday.

One of my patients is a 17-year old who went to the ER on Sunday for shortness of breath. They said she had a panic attack and should follow-up with me as soon as possible.

When I saw her, she was clearly distressed, but not to the point of needing to be hospitalized. I asked her what was up and she told me that she had been kicked out of school recently because she stabbed someone with a knife – apparently only after that person grabbed her forcibly. She lives with her mother and her father is a homeless alcoholic. Her mother tells her not to talk to him, but he calls regularly and tells her that she is all he has. He also says that he might kill himself. She knows that he shouldn’t say this kind of thing to her, but it puts her in a hard situation. On one hand, she knows that it tears her apart to talk with him. On the other hand, she fears that if she does not talk to him, he will kill himself.

I asked her if she ever thought of killing herself, and she said she had – especially after talking to her father – but was not at this time suicidal. She had a real good friend with her who was very supportive.

So I am stuck in a dilemma. On one hand, she is clearly depressed and needs both medication and psychological counseling. On the other hand, since there is a black-box warning for using SSRI’s in teens, putting her on one would put me at huge risk for a lawsuit should she follow-through and kill herself. I think she is at very high risk of doing that in the long-run, and don’t really have a longstanding relationship with her as her doctor. I did what I could to tell her to talk with either her friend or me if she should feel she is close to killing herself, but I don’t really know her that well. I am trying to reach one of the local child psychiatrists, but most of them are several months out for new patient visits. (more…)

Mental Health System is Worse than Bad

By Robert Lamberts, M.D.

When I get discouraged about the state of the healthcare system, I but need to look in one place to see that things could be worse: the mental health system. While there remains hope that there will somehow be reform and things will get better in the arena in which I work, it is very difficult for me to see anything getting better for the Psychiatrists.

One of my staff recently had a family member have a fairly major “breakdown.” I was caring for this person, mainly due to the fact that there are not close to being enough psychiatrists available to help. I have found that as a primary care doctor, I have had to become an “amateur psychiatrist” (as I call it) and diagnose and treat people whenever possible. Some of this is due to the stigma of people going to psychiatrists, but most of it is simply due to their unavailability. This was the case with this family member, and I did my best to address the needs medically, and even offered the best counselling I could.

Yet things went from bad to worse, and she ended up needing hospitalization, as she started having paranoid ideation and was very worrisome to the family that she might harm herself or her husband. I thought she simply had to go to the teaching hospital ER and they would either admit (voluntary) or commit (involuntary) her to the psych ward. I found out that the only place where an involuntary admission can occur is the state psych hospital. This was not the case when I started practice, but due to the total lack of fianancial viability of a locked psych unit, all of the others have closed down.

Of all of the places I have worked, the scariest one for me personally was at a state psychiatric hospital. This was not only scary due to the significant pathology in the patients (the worst of the worst), but the total lack of hope in that setting. There were not the financial resources available to really help those who needed to be helped, so they all were basically held there at the state hospital. It was the most helpless set of people I have ever seen.

I am sure my picture was somewhat jaded by my dislike of the clinical rotation, but it still paints a pessimistic picture of the reality of psychiatric care. These are the most needy patients, and the ones least likely to seek out care for themselves. If there is an area of healthcare that needs to be nationalized, it is psychiatric care. These people often cannot help themselves, and lack the resources to do so even if they could. I have no idea what a national psychiatric healthcare system would look like (I fear to think of it, honestly), but I don’t see many ways that things could get worse than the current system.

To all you psychiatrists out there, you have my deepest respect.

Personal Perspective of Manic Depression

By Tom Pauken II

“A Personal Perspective of Manic Depression: This reporter gives a first-hand account about the bipolar disorder” reprinted with permission from Mr. Tom Pauken II.

Bipolar disorder, commonly known as manic depression, affects 0.3 percent to 3.7 percent of the world’s population. Fifty percent of them seriously considered or attempted suicide. Forty-five percent of Americans with bipolar disorder believe this sickness made a high negative impact on their lives. Seventy percent of those same respondents assume the public doesn’t understand their condition.

These statistics were compiled by a Global Survey for World Mental Health Day 2005 (Oct. 10) also posted on the upliftprogram.com Web site. Are these statistics important? Do you know somebody afflicted with manic depression? Well, I consider these statistics important because I suffer from this ailment.

I make this revelation not to grab attention for myself. I’m more passionate writing about geo-political issues of the East Asia-Pacific region. I shun diaries and anticipate never using first person voice in future articles.

Nevertheless, I feel an obligation to my readers. I want those suffering from mental illness to feel inspired during their moments of darkness because I might be manic depressive but I’ve taken great strides to overcome my difficulties. (more…)

Interview on Self-Injury

Dr. Jane Chin: What are the biggest misconceptions or “myths” people have about self-injury?

Dr. Deborah Serani: I’d have to say that the biggest misconception about self-injury is that most people think that those who cut or self-injure are suicidal. Though any behavior that puts a person in harm’s way requires clinical evaluation, the basic reason individuals cut or self-harm comes from the wish “to control” or to “numb away feelings.”

Dr. Chin: Why is cutting or self injury such a difficult subject for people to talk about?

Dr. Serani: There is a lot of shame associated with this behavior. Seeing the scars or scabs serves as reminder to the person that they cannot find a better way to move through pent up feelings. They feel like they have failed or are flawed in some way, which exacerbates there negative feelings even more. (more…)

Neurodevices Target Depression

By Zack Lynch

From this month’s Neurotech Insights investment newsletter focused on the depression market:

While drugs to treat depression have proven effective for millions of individuals there exist a significant number of patients who do not respond to antidepressants. Treatment resistant depression, or refractory depression, is a condition that affects an estimated 4 million people in the U.S. and 11 million worldwide. Until recently, there were no options for these individuals beyond treatment with electroconvulsive therapy (ECT), which commonly induces memory loss among other issues. Today, several neurodevice approaches for the treatment of refractory depression are emerging including Vagus Nerve Stimulation (VNS), Deep Brain Stimulation (DBS) and repetitive Transcranial Magnetic Stimulation (rTMS).

The first neurodevice to be approved by the FDA for depression was Cyberonics’ VNS Therapy system. On July 15, 2005, the FDA approved Cyberonics’ VNS Therapy as a long-term adjunctive treatment for patients 18 years of age or older with chronic or recurrent treatment-resistant depression in a major depressive episode that have not responded to at least four adequate antidepressant treatments. Chronic treatment-resistant depression is defined as being in the current depressive episode for more than two years. Recurrent treatment-resistant depression is defined as having a history of multiple prior episodes of depression. The approved indication for use includes patients with unipolar or bipolar depression in a major depressive episode. (more…)

Public Access to Articles on Antidepressant Safety

Journal of Child and Adolescent Psychopharmacology is a peer-reviewed journal published by Mary Ann Liebert, Inc. The February/April issue (Volume 16, 2006) explored the controversial topic of using selective serotonin reuptake inhibitors, or SSRIs to treat depression in children and teens.

Peer Review: Peer review of a scientific publication is considered a rigorous process that makes a published scientific study a credible source of information. A panel of the researcher’s “peers” assess the submitted publication for scientific merit and objectivity.

This topic has been controversial because of the debate around safety and effectiveness of this class of drugs for what is considered a vulnerable population. Based on the potential impact of this controversy, the publisher has made this double issue free for viewing.

View: http://www.liebertonline.com/toc/cap/16/1-2

pills.gif The association between treating teens and children with SSRI drugs and an increased risk of suicide has made this a highly public controversy – including a past episode of Law & Order on television.

This journal is clearly aimed for healthcare professionals, researchers, and industry consultants. The publisher of the journal is a privately held media company that also publishes other magazines in biomedical research and biotechnology.

If readers are particularly interested in a specific article, I will be happy to help decipher it for you.

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