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Wednesday, January 26, 2011

Three Ways of Thiinking about Self-Esteem

I believe that there are three ways that people attempt to establish feelings of self-esteem.  Self-esteem has to be based on something.  We may base it on our achievements, our relationships, our intelligence, but it has to be based on something.  Let's look at three ways that people try to develop feelings of significance:

1.  Spiritual/humanitarian ways of thinking about self-esteem.
2.  "Normal", everyday ways of thinking about it.
3.  "Neurotic" ways of thinking.

First of all, what do I mean by "Spiritual/humanitarian"?  This could include Judaeo-Christian beliefs, such as the idea that we are all created by God.  It could be the idea that we have value because we are human beings.  It could be based on values, such as the importance of honesty and integrity in living one's life.  It could be based on the idea that all human beings have innate worth no matter who they are or what their situation.

Then there is the "normal" or "everyday" ways that people base self-esteem.  We feel good about ourselves when people like us, when we do well on a test, or when we achieve something.  We feel good when we are attractive and people seem to want to be around us or to date us.  We feel good when we are sought out for our skills.  There is nothing wrong with these, and they can be healthy.  But these ideas sometimes let us down.  That is, sometimes people don't like us.  Sometimes we don't do well on tests.   And sometimes we lose a job.  Moreover, many of these things don't really change anything inside of us.  That is, if somebody likes me, it doesn't reach inside of me and make me a better person.  And the same person who likes me today may disapprove of me tomorrow.  I can't have changed over night.  So some of these are more externally based than internal to us.  And if they are external, then they can't really have that much to do with us and our significance.  It's okay to feel good about these things, but they can let us down.

Thirdly, there are the "neurotic" ways of basing self-esteem.  The word neurotic is a somewhat dangerous word.  It has no clear meaning, and people can use it against themselves as another negative thought.  In cognitive therapy, we might call these "dysfunctional assumptions," or "irrational beliefs."  Call them what you will, they can cause self-esteem problems.  Some of these I have already written about:

  • I must be approved of by everyone to be worthwhile;
  • I must be loved by the person that I loved to be worthwhile;
  • I must be in control at all times to be worthwhile;
  • I must achieve great things to be worthwhile;
  • I must be perfect to be worthwhile.
There is nothing wrong with wanting people to like us.  There is nothing wrong with wanting to be loved.  And so on.  But the neurotic beliefs are inflexible.  They do not allow for our humanity and for the ebb and flow of human experience.  We will not always be perfect, and we will not always be liked.  We will not always achieve.  We will not always be loved by the people that we want to be loved by.

It is sometimes possible to meet the neurotic beliefs for awhile.  We may be the smartest in our school--for awhile.  We may be the most popular--for awhile.  We may be the most beautiful--for awhile.  But these canl not always be true for all times and all situations.  And when the neurotic need or belief is not met, we will feel a tremendous sense of let down, and maybe even depression.

So in my way of thinking, it is good to start with a religious or philosophical base for our self-esteem.  Then we can build on top of that with the things which will sometimes work for us and sometimes won't--the success, approval, and love that most of us want.  And we need to stay away from the inflexible and problematic neurotic beliefs which can really hurt our self-esteem.  If we set up overly stringent standards for ourselves, we will fall short at some time.  It is inevitable that at some point we will not meet the standard.  And to be frustrated by the inevitable is to be inevitably frustrated.

Monday, January 17, 2011

Spirituality and Psychology

Increasingly, psychologists are recognizing the importance of spirituality.  In a recent article published in the American Psychological Association magazine for psychologists, "A Reason to Believe," Beth Azar looked at some of the psychological benefits of spirituality. 

She noted that since Sigmund Freud, some psychologists have seen religion as unhealthy.  However, research is now showing that it is in many ways just the opposite--a very important part of human existence.  Despite the 20th century movements of communism and atheism, 85% of the world still has some type of religious belief.

One important role of religion is to create "increasingly larger social groups, held together by common beliefs."

Religion provides a sense of certainty during times of angst and uncertainty.  People search for meaning and order and find comfort when they find it.

To some degree, the tendency to believe may be innate, and it may have to be "taught out of us."  One psychologist found that "children as young as age 3 naturally attribute supernatural abilities and immortality to “God,” even if they’ve never been taught about God, and they tell elaborate stories about their lives before they were born, what Barrett calls “pre-life.” "

Some areas of the brain have been found to be more active during religious contemplation.  Buddhist monks who were meditating  used the attentional areas of the frontal lobes more intensely.

Spirituality seems to lead to people having longer lives.  Religious persons live longer, have less depression, abuse substances less, and may take care of their health better.

Religion also leads people to be more prosocial.  They are more cooperative and more fair with strangers.

There is much more that could be said here.  The field of the psychology of religion keeps growing.  Some researchers are believers and some are not.  Either way, we've come a long way  since Sigmund Freud and the knee jerk reaction that says that religion is pathological.

Sunday, January 16, 2011

Captain Kirk and Mr. Spock

Why are the Star Trek movies and TV series with Captain Kirk and Mr. Spock so popular?  And what have they to do with psychology?  After watching the new Star Trek sequel for the umpteenth time, I have realized that the Kirk/Spock duo represents many of the dualities that all of us experience in our own brains.  Kirk is more intuitive (right side of the brain), and Spock is more linear in his logic (left sided).  Kirk is more impulsive (limbic system), and Spock more restrained (frontal lobe executive functioning).  Kirk is more emotional (again limbic system), and Spock is again more restrained. 

Of course, Kirk would make a lousy starship captain if he were only a limbic system with a little bit of right sided neocortex.  But still, he and Spock clearly embody the conflict(s) that occur between different parts of the brain. Perhaps one of the reasons why we enjoy watching them so much is that we experience these conflicts every day of our lives.  In each situation, we have to decide whether to respond out of logic or out of emotion. 

From a neuroscience point of view, the question is whether we only get to use one part of our brain at a time, or whether we get to "have it all"?  That is, does one part of brain have to win out over the other part in each situation?  Or do we get to integrate the different parts so that "all of us" gets to participate in different situations? Ideally, we get to integrate the different parts so that "all of us" gets to participate in any situation.

It is interesting that in the sequel, Kirk lands at the top of the hierarchy once again.  We wouldn't have it any other way would we?  We don't want to lose our humanity--our emotions and the ability to act slightly impulsively at times.  But the whole sequel movie is a conflict.  It is not resolved quickly and easily.  And maybe our brains are relishing every moment of the conflict, then getting to observe a nice neat resolution at the end.  We, however, don't have a nice neat resolution.  We continue to struggle every day of our lives trying to figure out just how we are going to resolve the conflicts inherent in our own brains.

Friday, January 14, 2011

Rewiring Our Memories, Removing Fears, and Treating PTSD

The future of the treatment of PTSD (Post Traumatic Stress Disorder) may lie in a unique combination of psychological and pharmacological intervention.  In the past, these two have been used separately, or side by side, but not actually in an interactive way.

Memories, it turns out, are not as permanent as we once thought.  Once a memory is activated, the brain then turns around and reconsolidates it.  However, if this process is interfered with, then the reconsolidation process doesn't work quite right.  If there is an emotional memory (such as a car accident, or a battle), the fear can be stripped away from the objective memory by interfering with the reconsolidatoin of the fear memory.

In the original research on this issue, researchers made rats fearful of a situation.  Then they found a way to make the rat recall the situation.  But they also gave the rat a protein synthesis inhibitor (with the theory that memory formation involves protein formation in the brain).  The rats no longer attached fear to the situation as they did before.

This could ultimately be one of the biggest breatkthroughs in all of psychotherapy, finding a way to detach painful, overwhelming feelings from past memories.

Currently, the protein synthesis inhibitors are not available for clinical use.  Beta-blockers (heart medications) are being used instead, which may or may not prove satisfactory.

Thursday, January 13, 2011

Testing For Attention Deficit Hyperactivity Disorder

How does one go about testing for ADHD?  Ideally, there will be multiple viewpoints and data sources.  The major data viewpoints are:

  • clinical interview with patient and parents, if the patient is a minor
  • some basic measures of depression and anxiety (these have to be ruled out as causes of ADHD)
  • some rating scales to be completed by the patient
  • rating scales to be completed by the parent or spouse
  • rating scales to be completed by teachers
  • a computerized test of attention (vigilance)
  • sometimes, an IQ test (more about this below)

Let's take these one at a time.

The clinical interview is absolutely necessary.  It is important to hear what a patient has to say, and it is also important to observe their behavior.  I usually conduct a full clinical interview.  That is, I don't just assume that the problem is ADHD.  I ask about all typical areas of childhood problems, including depression, anxiety, psychosis, and even eating disorders.

When it comes to the ADHD symptoms specifically, I ask the child first what their thoughts are about a symptom (e.g., "Do you have a problem keeping your attention going in class?") and then ask the parent for their opinion, so that I have both perspectives.

I use a self report depression inventory and a children's anxiety inventory, which I read to them.  Depression and anxiety can cause attention problems.  I also want to know if their ADHD is causing them to have low self-esteem or depression.

If the child is a teenager or older, I use a self-report ADD questionnaire.  There are ADD questionaires for children, but generally I only use self-report questionaires for teenagers and adults.  I use the Brown ADD Self Rating Scale for ADD.

I also use the Behavior Rating Inventory for Executive Functioning.  This measures executive functions, which I have written about elsewhere.  It measures nine different types of executive functions. 
  • Problems with self-monitoring (being aware of how one is acting and how it is affecting others)
  • Problems with initiating tasks
  • Problems with working memory (being able to keep things in short term memory to perform actions on them, such as remembering a phone number from the time of reading it in a directory to the time of dialing)
  • Problems with planning and organizing time
  • Problems with task monitoring (being aware of whether a strategy on a task is working)
  • Problems with organization of materials
  • Problems with inhibiting impulses–causing acting out and impulsivity
  • Problems with shifting from one task to another when needed or shifting from one problem solving strategy to another when one is not working
  • Problems with controlling and modulating (smoothing out) emotions

I use the Conner's Continuous Performance Test-II to measure vigilance over a 15 minute period of time.  The Conner’s Continuous Performance Test-II is a computerized test of attention which lasts approximately 15 minutes. It does not measure brief bursts of attention (as measured by some of other types of tests); rather it measures the ability to continue to attend to a simple vigilance task over a period of time.
I use the WISC-IV or WAIS-IV to measure IQ.  I am not really all that interested in IQ.  IQ is in my opinion an oversold concept.  The full scale IQ of someone is not nearly as interesting as understanding what their strengths and weaknesses are.  The Wechsler scales have four major indexes and a minimum of ten subscales.  I want to know if the child's IQ accounts for their problems in school.  I also want to know if they are showing any problems with working memory.  Other items of interest on the WISC or WAIS are the comprehension subtest, measuring social comprehension and the processing speed subtests.

Sometimes, a measure of intelligence is needed, particularly if there has been poor school performance. However, the IQ measure does not really tell us much about whether ADHD is present. Instead, it helps us to know whether the child is underperforming in school, or whether poor grades are perhaps due to something else. Sometimes, a learning disorder is thought to be present, and an achievement test may be needed. Usually, learning disorders are diagnosed by comparing achievement testing with IQ tests. Learning disorders are often present in ADHD. However, ADHD proper does not need IQ tests or achievement testing for diagnosis.

Wednesday, January 12, 2011

The Problem with Being Nice

In our culture, we often teach girls (and sometimes boys) to be "nice."  Nice people are easy to get along with.  And they probably serve an important function in our society, helping everyone to get along.  They are conciliators.  I enjoy being around nice people.

However, "nice" people are often not assertive.  They have been taught to sacrifice themselves and their own feelings for the sake of pleasing others.

In fact, one of the dictionary meanings of the word "nice," is "pleasing."  To be always pleasing to others can mean sacrificing ourselves and our own needs.  It can also cause anger to build up inside of us, so that it may eventually come out in a blow up.

There is nothing wrong with being "loving."  I would view being "loving" as an active emotion.  It can be very benevolent.  But it is not always "nice."  If a child is acting up and needs to learn better, prosocial behavior, they may need to have firm limits set on them.  And the same is often true for adults.  If we really care about someone else, we sometimes need to speak up to give them feedback about how they are behaving.  But this may not be perceived as "nice."

However, I am not advocating the opposite.  I am not advocating being grouchy, rude, unconsiderate, or aggressive.  Those attributes carry with them their own problems, both for oneself and for others.

Being "nice" can take its toll on a person.  It encourages passivity rather than activity and assertiveness.  Be benevolent.  Be loving.  Be active.  Be creative.  But watch out about being too "nice."

Tuesday, January 11, 2011

Teaching Children How to Do the Hard Thing

There are many theories about how to raise children, and many have a great deal of truth to them.   For example, I like the ideas emphasized by concepts such as nurturing, using positive reinforcement, modeling positive behavior, and so on.

I want to write today about one part that may be overlooked--the development of good frontal lobe functioning by teaching children to do the "hard" thing.

I remember one child saying to me in therapy, "I know how to do the (math homework) questions, so why do I have to keep doing more and more math problems?"  There are probably a variety of good reasons for this.  But here is one:  Life often requires us to do the hard thing, to persevere, and to "hang in there" when we would just  like to give up.

The act of persevering is stimulating to the brain.  We are learning how to do the hard thing.  We are learning how to motivate ourselves, to organize activities, and to find ways of staying with them until completion.  All of this builds better neural systems in the brain.  Learning how to do anything builds neural networks.  Doing 20 math problems instead of two is building at least two different sets of neural networks--one for math, and one for perseverance.

If I could give my children just two sets of cognitive abilities, one would be to have a good sense of values, and the second thing, right behind it, would then be a good set of frontal lobe executive abilities.

The term "executive function" is not widely used in our culture--yet. It refers to the function of the prefrontal lobes.  Other lobes of the brain may have primary sensory  (e.g., visual or auditory) functions or primary motor function areas.  There are no such primary sensory or motor areas in the prefrontal lobes.  That is the area which ties everything together and makes things happen.  Hence it is termed the executive function area.  Think of a manufacturing business.  One part of it takes in raw materials.  Another arm of the business transforms raw materials into a product.  Another arm of the business ships out product.  Another arm of the business collects money.  But the executive administrative offices may not appear to be doing anything at first glance.  Yet they tie everything together and make things happen.  The same is true of the prefrontal region of the brain.  They tie everything together and make things happen.

My chance to teach executive functioning to my children is over. And fortunately, my grown children seem to have excellent executive functions. Maybe I will have a chance to do that next with grandchildren, although it won't be up to me how to structure my grandchildren's lives.

But I hope that in the midst of a loving, tender, caring home with good role models, that they will also have to learn to do the hard things in life.  (I am not saying to do the hardest things, but hard enough to develop those prefrontal neural networks.)  I hope that when they reach adulthood, their prefrontal regions have been well developed and well established.  Then, when combined with a good set of values, they will be in a good position to reach their goals.

Monday, January 10, 2011

Reasons Not to Commit Suicide

One of the issues that all mental health professionals have to deal with is helping people past suicidal thoughts at times.  Life can become so painful that suicide may seem like the way out for some people.  Here are some of the things which I tell my own clients when this issue comes up.

Suicide is closely related to hopelessness and to negative thoughts about the future. Persons who commit suicide are generally convinced that there is no other way out for them. This is not true. There are better solutions to problems than suicide. If you are concerned that your depression will always be with you, then keep in mind the fact is that even severely and chronically depressed individuals can have long periods of time in which they are not bothered by depression or mood swings. Most depressions come to an end and do not go on forever.

Since hopelessness is so closely associated with suicide, it is vitally important to find a reason for hope. In this regard, it is important to avoid catastrophizing and fortune telling. The suicidal person believes that the future will be bleak and full of despair. Some examples of typical fortune telling thoughts are:
“I’ll never get over this depression.”
“I’ll never be happy again.”
“Now that I’m divorced, I’ll always be alone.”
“I’ll never find someone else that I can love or who will love me as much.”
“I’ll never find another good job. I’ll always be scraping by from now on.”

The suicidal person often anticipates that something dreadful and intolerable is about to occur. However, the future is almost never a sure thing. There is no way of knowing with certainty what is going to happen. Even if it appears fairly definite that something bad will occur, it may be that you are not just afraid of the event itself but of something which you think will follow it. For example, if you are sure that your spouse is going to get a separation, maybe what you fear most is the idea that she will take the children away and that you will never see them again. The likelihood of a separation may be almost certain; the probability of divorce may be somewhat less sure; and the chances of her taking the children away where you could never see again them are even less likely. The farther into the future a person is predicting, the more doubtful it is that their fears will actually come true.

Suicidal individuals often have the thought that others will be better off without them. “No one would miss me if I’m gone.” “I’m worth more to them dead than alive.” These are examples of the extremely distorted thinking that can occur in depression. The grief, pain, and suffering of family members after a suicide is often overlooked or discounted by the depressed person. Suicide is not a noble act. It is does not take a burden off the family--just the opposite. It is a desperately self-centered act which can burden survivors with feelings of guilt, anger, and depression for years to come. It is important to realize that underneath the selfless sounding words of “taking a burden away from the family” through suicide, the depressed person is sometimes actually very angry.


Suicide is often more of an expression of anger than selflessness. When this is realized, then the suicidal person can find more appropriate ways of dealing with their anger.

Suicide can be thought of as a last ditch, desperate means of solving a problem. The problem usually consists of an external component (such as a legal problem or a relationship disappointment) and an internal feeling of pain. The person usually feels that all possible means of dealing with the problem have been exhausted and that there are no good alternatives left. Usually, this is not true, although it may be necessary to get help from a friend or therapist to see the alternatives which have been missed. Get someone to help you see some new solutions to problems that you have not yet been able to see. Get away from any rigid, all or nothing thinking. When persons are stuck in trying to solve a problem, they often feel that there are only one or two ways to solve it. When they feel that neither of them is working, then they tend to feel helpless and hopeless. In reality, there are often a variety of solutions to a problem. None of them may be perfect, but almost every one of them is likely to be better than suicide. Oftentimes, there may be multiple problems, which is particularly confusing to a person who is already depressed, tired, and having difficulty concentrating. A therapist can be very helpful in pulling apart the different problems and helping to find solutions for each.

Distracting Yourself Until Suicidal Thoughts Pass

Usually, suicidal thoughts don’t last for more than a few hours at a time. By remembering that such impulses usually pass, it is easier to find ways to distract yourself temporarily. If you can get past the moment, then you may change your mind about wanting to kill yourself. The first step is just to get through the night or the next few hours. Contact a friend. Then reconsider your situation. Delay acting on your suicidal thoughts. Keep your choices open. As long as you are living, you have the choice to stay alive or not to. But once you are dead, you have no choices. Give yourself the chance to change your mind. Once the crisis passes, develop a plan for how you will deal with the thoughts and impulses if they occur again.


Obtaining Help and Social Support

Don’t isolate yourself. It is vital to garner social support. It’s time to call in your favors from people. This is no time to be independent and strong and to try to go it alone. Suicidal thoughts and actions are often triggered by the loss of a relationship. If you have lost a person through divorce or death, then your needs for companionship are likely to be greater. You may be feeling intense loneliness. Ask for help. Set up a support network of individuals who understand your feelings and who agree ahead of time to be supportive.

If there is a family crisis behind your urges to kill yourself, it may be helpful to turn to the member of the family who is most stable, supportive, and calm for help. Let that relative know that you have a problem and what it is. See if there is something they can do tho help you through the crisis.

If you feel that you are facing overwhelming demands that you cannot possibly fulfill or carry out by yourself, ask for help from others. If your family is not willing to provide the support that you need, there are people who will be glad to help you, such as local telephone hot lines, depression support groups, church groups, friends, a therapist, a minister, and others.

Form a strong relationship with your therapist. They are there to help you. If you feel that you need more frequent sessions with your therapist, ask for them. If your therapist does not seem to give you the amount or kind of support that you need, discuss that issue in your therapy session. Find out what the rules are about contacting them in a crisis. However, don’t stop at finding out what the therapist’s guidelines are.

Making a Contract

Make a contract with a friend or family member to stay alive. Have a firm agreement to call them and to see them before hurting yourself. Some persons are leery of making such a contract. They feel that they are giving away their freedom to someone else. Two things need to be said about this. First, you are not giving away your freedom. You are preserving it. As already mentioned, dead people are not free; only living people are free. Secondly, if you cannot make an indefinite contract, make a contract for a limited period of time--a month, two weeks, or even one week. That way you are not committing yourself “forever.”

Create a contract between you and your therapist that you will not harm yourself before coming in for another session. (It is not enough only to contract that you will wait until talking with them on the phone).

Avoiding Alcohol and Drugs

Avoid substance use because it increases the chances of following through on suicidal thoughts. Drugs and alcohol impair judgement and lower a person’s inhibitions. Moreover, alcohol and many drugs are depressants. If you need a medication to help you feel better, get a prescription for an antidepressant or anti-anxiety medication from a physician. However, make sure that the doctor knows that you are suicidal so that she can prescribe one which cannot be used to harm yourself.

Give Away Any Means of Suicide

Make it harder for you to kill yourself on a whim or an impulse. Give any lethal medications or weapons that might be used to hurt yourself to someone else. Get rid of all guns in the house. Don’t leave temptation lying around. You may even need to avoid driving at times if you find yourself having the impulse to wreck your car.

The Two “Yous”

There are in reality two ”you’s”. There is the suicidal you in the present, and then there is the you in the future that will be glad to be alive. Your therapist and friends are trying to keep you alive because they know the future “you” will be happy to still be living. Not all of your personality wants to commit suicide. The fact that you are still alive to read this means that a part of you has not wanted to die and has kept you alive up to this point. Remember that suicide is a permanent solution to a temporary problem.

Sunday, January 09, 2011

What Is the Difference Between a Psychologist and a Psychiatrist?

This is a confusing question for many people, but also a very important one, as people seek out help with mental health issues.  Do they need a psychiatrist, or a psychologist, or a social worker, or a licensed professional counselor?  Some states have other licenses and certifications as well (such as marriage and family counselor).  I'm just going to deal here with the distinction between a psychiatrist and psychologist.

There is a basic difference in training and in method.  In the beginning of psychiatry (early 20th century or late 19th century), there was a beginning in medical research, neurology, and Freudian theories.  In the beginning of psychology, there were laboratory studies of animal behavior, study of child development, and school psychology.  These two different beginnings led to two somewhat different perspectives on human behavior, each valid and useful.

In addition to there being differences in perspective, there are differences in training.  A psychologist gets a four year bachelors degree, then four to six more years for a Ph.D. and a year for internship.  Sometimes there is an additional year or two of a postdoctoral fellowship.

A psychiatrist gets the four year college degree, then four years of medical school, and then four years of residency.  If they are a child psychiatrist, there are two more years of residency for that specialization.

Then in addition to differences in training, there are differences in treatment methods.  Both psychologists and psychiatrists can do psychotherapy.  However, in the United States, psychiatrists often see patients for 10-20 minutes for medication treatment, leaving the psychotherapy for non-MDs.  Psychologists, on the other hand, spend most of their time doing psychotherapy, usually 45-55 minutes at a time.  Psychiatrists can prescribe medication and order laboratory tests and interpret them.  Psychologists cannot.  And while theoretically psychiatrists can do some basic psychological testing, it is not really part of their training, and they usually do not attempt it beyond short questionnaires.  Psychological testing is often a major part of a psychologist's training.

Oftentimes, a psychiatrist and a psychologist will refer patients to each other and have a close working relationship.  For some professionals, however, there is more of an antagonistic relationship, which is unfortunate for patients.  Much of the research literature suggests that combined psychotherapy and pharmacotherapy is a superior treatment to either alone.  So it is usually in the patient's best interest to have the option of seeing both a psychiatrist and a psychologist.

If you are seeking out treatment, you may want to consider seeing both a psychiatrist (or some other physician) and a psychologist (or some other non-MD psychotherapist).  But which one do you go to first?  The answer is generally that the more severe the symptoms are, the more logical it would be to start with a psychiatrist.  If there are hallucinations, delusions, or an inability to go to work, then medication is generally  necessary.  However, if the issues are milder, or if there are family or relationship problems, then starting with a psychotherapist is generally a good idea.

Saturday, January 08, 2011

Don't Let Your Grief or Loss Turn into Depression

Very often, I work with people who have recently suffered some type of important loss in their life, usually a spouse or significant other.  The loss can be through death, divorce, or the break up of a relationship.

This process is almost always painful, but it is important in these situations to separate out the necessary pain from the unnecessary pain.  The necessary pain is the grieving.  Grieiving is the way that the mind detaches from someone with whom the grieving person has bonded.  Grieving hurts badly, and I wish that it was not necessary, but it is.

On the other hand, depression is not necessary.  Depression is more severe, more pervasive, more disabling, and to some degree has a different symptom picture.  "Uncomplicated grief" is different from grief that develops into depression:
  • In grief, the negative thoughts tend to be more realistic, such as "I will miss them terribly," or "they were unique," rather than "I will always be alone" or "There is no one else that I can be happy with."
  • Similarly, feelings of worthlessness are not part of grieiving.  To the degree that guilt is present, in grieving the feelings are limited to specific incidents regarding the deceased; in depression, it may be more pervasive or illogical.
  • In grief, suicidal thoughts are usually not present.
  • In grief, there is usually not the intense psychomotor slowing (slowed thoughts and movements).
  • In grief, there is usually not too much work impairment.
  • Depression tends to be more pervasive, and nothing may lead the person to feel much better, whereas in grieving, the support of friends and family is more likely to help the person.
There are probably at least four pathways by which grieving becomes depression.

Pathway #1.  Negative thinking.  In this pathway, the person doesn't simply miss the person that has died or left them; they attach very severe negative interpretations to it.  "I'm a loser; I will never find anyone else; I'm ugly; it is my fault that he left me; I'm being punished by God by Him taking my husband away."

Pathway #2.  Excessive withdrawal from life.  Many of us have a tendency to withdraw and "lick our wounds."  To some degree this is normal.  However, it is quite possible to withdraw so much that we interrupt the flow of our daily lives.  We pull back from life so far that we cannot recieve any social support.  We may pull back from pleasurable experiences in general.

Pathway #3.  Triggering an underlying genetic tendency towards depression.  For some people, the depression is not due to what they are doing or thinking but to the way their brain responds to stress.  They may have already experienced major depression in their life.  In this case both medication and therapy may be needed.

Pathway #4.  The triggering of old memories.  The loss of someone in adulthood may trigger painful, unresolved feelings from some event very early in life, such as the death of a parent.  Again, therapy might be helpful in this situation.

In general, when I am helping someone who is going through this process, I try to allow them to grieve in whatever way is comfortable to them, but within limits.  I try to keep them from falling into the trap of excessive negative thinking, or from pulling back so much from life that they have no enjoyable experiences.

Friday, January 07, 2011

Can Bipolar Disorder Cause Dementia?

We normally think of bipolar disorder as a treatable for most patients.  My experience is that if the patient is compliant with treatment (and that is a big "if"), then symptoms can be mostly controlled. 

Unfortunately, there is some evidence that some persons with bipolar disorder may eventually develop more enduring memory problems and other cognitive deficits.  I frequently have bipolar patients referred to me for assessment of memory problems or evaluation for possible dementia, and usually I do find mild to moderate problems. 

Most of the patients referred to me in this situation are in their fifties, not in their sixties, seventies, and eighties, as usually occurs when I am testing patients for dementia.  This suggests to me that there is something very different about this process than Alzheimers.  It seems to develop earlier in life, causing problems in one's job.  In addition, the patient seems to have more insight that they are having problems, whereas many of the patients with Alzheimers are brought by their family members and do not have insight that they are having cognitive problems.  However, if there is such a thing as a bipolar dementia, we do not as yet have a clear picture of what t would look like in terms of specific symptoms like to differentiate it from Alzheimers, ischemic dementia, and so on.

In a situation of testing a person with bipolar disorder, it is always possible that their memory problems are actually due to their depression.  Depression causes a generalized decrease in brain function and interferes with memory.  And so, part of the evaluation always has to be looking at the current severity of depression.  But the cognitive deficits associated with bipolar disorder do not appear to be linked to whether the person is currently depressed or not.  There seems to be something else going on.  It is possible for example that the excessive cortisol release caused by depression and mania over the lifespan have damaged the hippocampus, so that even after depression improves, there is a memory problem.

Three factors tend to make the problem worse: older age, having an onset at a younger age, and having a more severe illness overall.  There is some evidence that the more episodes of depression and mania, the greater the cognitive deficits may be.  Thus, the cognitive deficits in later life may be preventable if persons take management of their illness seriously and treat it conscientiously.

Problems occur in other aspects of brain functioning besides just memory.  These include problems with executive functioning, concentration, and visuospatial skills.

The cognitive problems appear to be persistent and sometimes severe, so that sometimes a diagnosis of dementia may be appropriate.  Usually, I do not diagnose dementia with these patients because the symptoms are not quite severe enough.  I use the milder DSM-IV diagnosis of Cognitive Disorder Not Otherwise Specified. Until we have more information about the reversible or irreversible nature of this illnes and how it responds to treatment, I prefer to use the less serious diagnosis.

Wednesday, January 05, 2011

Psychological Testing for Dementia and Alzheimers

I have written a little already about psychological testing in general.  One of the types of testing which I mentioned is testing for dementia.

People often confuse dementia and Alzheimers.  Alzheimers disease if a form of dementia.  Often, it is difficult to tell the difference between Alzheimers and other forms of dementia.  What are the other types?  Ischemic dementia involves disease of the small blood vessels of the brain, with occlusions (or blockages) starving brain cells and causing small areas of death.  The areas may be small, but the process is occurring over and over.  Ischemic dementia is also called white matter disease (because the small strokes are occurring in the deep whtie matter) or multi-infarct dementia (because of the repeated small infarcts, or strokes).  Sometimes multi-infarct dementia can be detected by the "spotty" pattern of results.  That is, a patient does well in some areas and poorly in others, rather than doing poorly across the board on cognitive tests.  There are other dementias as well.  Frontotemporal dementia is somewhat different from the other dementias because its meain features are problems with impulsivity and executive functions.

Here is a basic dementia battery that I generally use:

Clinical interview--There always has to be a clinical interview.  And there generally needs to be collaborative information from family, radiological results, nursing staff, etc. The clinical interview needs to rule out other possible causes of memory loss and cognitive dysfunction besides dementia, such as severe depression, anxiety, medication effects, and so.  The interview also looks at current medications, history of head trauma, alcohol and drug abuse, and so on.

My own habit is to look next at the Geriatric Depression Scale.  I always want to know next how depressed the person is, mainly because severe depression can cause memory problems.  On the other hand, cognitive problems can cause people to become depressed, either psychologically depressed, or through more direct biochemical pathways.

For a cognitive screening, I use the Dementia Rating Scale.  Many people use the Mini Mental Status Exam (MMSE).  I find that the DRS gives a better screening.  It looks at attention, initiation of tasks, graphomotor functioning, abstract thinking, and memory.  By the time the DRS is over, I have a rough idea of whether the person is actually having any significant cognitive problems or not.  If so, I don't know what is causing them; I just know whether there are any gross problems.

I look at spatial functioning using a simple clock drawing test, and I look at ability to find words using the Boston Naming Test.  A straightforward verbal list learning test is also part of my screening batter.  If the dementia is severe, sometimes this simple battery is all that I need to answer a referral question.  If the cognitive impairment is less severe or uncertain, or if very specific information is wanted, I use a longer battery of tests.

For example, I use the Wide Range Assessment of Memory and Learning-2 to assess verbal memory, visual memory, attention, delayed recall, and recognition memory.

The Wechsler Adult Intelligence Scale-IV is an IQ test, but IQ is not really what we are looking for here.  We are looking at the pattern of results.  There are some patterns more suggestive of dementia than others.  Verbal abilities such as vocabulary tend to remain at the same level during cognitive decline compared to the loss of perceptual organizational abilities.  The IQ test allows us to look at such patterns.

If I suspect a frontal lobe problem, then there is a test which includes several tasks measuring frontal lobe functioning.

What else could be done?  Well, there are other tests, but in my experience the above tests usually provide the information which is needed for diagnosis.

Followup to the testing involves a feedback session with the patient and their family.  The main question which they usually have is whether the memory loss is permanent and whether there is any treatment for it.  I usually tell them to talk with the psychiatrist, but I tell them that most dementias do not get better.  (Some insults to the brain, on the other hand, do heal.)  I talk with them about medication being available for some dementias.  I also talk with them about maybe seeing a rehabilitation psychologist to help them learn ways of improving memory, or if not improving it, at least compensating for memory problems.

Five Neurotic Beliefs

The word "neurotic" has been used in so many different ways that it hardly means anything anymore.  So, first let me explain what I mean by neurotic in this context:
These are general ideas which a person may have.  They are not just specific negative thoughts, such as, "I'll make a bad grade on this test."  They are more general, such as "I have to be perfect in everything I do--all times, and all places, and all circumstances.

Secondly, these thoughts often make people feel bad much of the time, because they are so hard to live up to.

Thirdly, they generally do not help us to live more productive lives.

Fourth, they are inflexible and rigid.

Here are some of the dysfunctional attitudes about self-worth which are common:

  1. I must achieve in everything I undertake or I am not worthwhile.
  2. I must be approved of by everyone. If someone dislikes me or disapproves of me, there must be something wrong with me.
  3. If I am not always in control of my feelings and actions, then I am weak. And if I am weak, I am worthless.
  4. I must be loved to know that I am valuable.
  5. I must do everything I do in the best possible way (that is, perfectly) or I'm not worthwhile.
This last one, perfectionism, is particulary important with regard to depression.  Perfectionistic attitudes have been found to be particularly prone to cause depression. In one study of persons in treatment for depression, the higher the levels of perfectionism, the less likely it was for the person to improve. It didn’t matter whether they were in cognitive therapy working on negative thoughts, receiving medication, or in some other form of treatment. Perfectionism was a roadblock to significant improvement in all the forms of therapy offered. The implications of this are very clear. Although some depressed persons see perfectionism as a very logical approach to life, it is actually a landmine in the road to success and happiness.

It is not always necessary to deal with underlying negative attitudes to get out of depression. Clearly, there are times when circumstances improve or when the passage of time helps the person to feel better. However, when negative assumptions are not dealt with, then the person is likely to be just as vulnerable to future depression if stresses occur again. It is not easy for people to change these attitudes by themselves, and discussions with a therapist are often helpful and sometimes necessary.

Here are some questions to think about:

1. What kinds of stresses have caused you to be depressed in the past? Does this tell you anything about your depressive attitudes? For example, have you tended to become depressed following relationship breakups? Being disapproved of by someone important to you? Experiencing school failure or a job setback? How about after making a mistake?

2. What kinds of stresses have not depressed you in the past?

3. As you consider your answers to questions 1 and 2, does it appear that there are particular kinds of stresses to which you are most vulnerable?

4. Rate yourself on the following underlying attitudes.

Attitude Strongly Disagree Disagree Not Sure Agree Strongly Agree

If I fail at something, it means that I am inadequate or worthless.
If I do not accomplish something which is very important to me, then I am a failure.
If someone that I love does not love me, then it means that I am unlovable and worthless.
I must be approved of by everyone. If someone dislikes me or disapproves of me, there must be something wrong with me.
If I am not always in control of my feelings and actions, then I am defective and/or weak.
If I do not strive for perfection, I am likely to turn out to be mediocre and worthless.

Depressive Attitudes and Stress Are an Explosive Combination

Depressive assumptions and stressful life events can team up to cause low self-esteem and depression. For example, consider what happens with the following combination of a depressive attitude and a corresponding event:

Attitude "I am worthwhile only if I am loved."  + Event "My husband left me."  =False conclusion "I am worthless."

In this case, the attitude and the event go together to create feelings of worthlessness and depression. The particular attitude and the particular event fit together hand in glove. Making a “D” in a course or even an “F” might be less likely to trigger depression in the above person, given their basic attitudes about what makes them valuable. The person is basing their self esteem on love, not on success. (The exception to this would be if they thought that people would love them less for making poor grades.)

Each of the depressive attitudes can lead to low self-esteem or feelings of worthlessness if the right stress occurs. Think of it as a jigsaw puzzle in which certain pieces fit together. If a person believes they must succeed and do well in everything they attempt, then not getting an expected raise or promotion can be a severe blow to their self-esteem. It may even lead to clinical depression. On the other hand, if members of his family are upset with him and avoiding him, it may cause upset, but still not result in depression because his underlying attitudes regarding self-worth are not based on love and approval.

Here are some of the logical problems with each of the dysfunctional attitudes.
1. "I must do everything perfectly":

Problems with This Way of Thinking:
--Trying to do everything perfectly may so overwhelm a person that they may never get started. They may then get less done than if they tried to do a good or adequate job.
--A person may spend so much time on details that little work gets done overall.
--Doing things perfectly is not really possible. Thus, it is inevitable that the person will feel inadequate at some point.

2. "I must succeed in everything I undertake. I must never fail or else I am worthless."
Problems with This Way of Thinking:
--It is not possible to always avoid failure.
--If an individual fails at one thing, is she supposed to ignore and overlook all of the things that she does right?
--This way of thinking can cause such a fear of failure that a person will not take even minor risks. This can cause them to be immobilized.
--Some of the people who have accomplished the most in history have had significant failures as well as successes.

3. "It is terrible to be disapproved of. If someone disapproves of me, I must have done something wrong."
Problems with This Way of Thinking:
--It is not possible to please everyone.
--If it appears that we are pleasing everyone, we are probably only succeeding in being wishy-washy and having few if any real principles.
--This would mean that other people’s opinions are automatically more valid than my own.
--Since someone will always disapprove of us, we are doomed to always feel inadequate and unhappy.

4. "I must be loved to know that I am valuable."
Problems with This Way of Thinking:
--Whether we are loved does not change our intrinsic self-worth. It is very important to be loved, but it does not reach into the core of our being and change who we are.
--If we must be loved to feel worthwhile, we are likely to be a doormat in a relationship for fear of losing it.
--A person's value to society comes more from the love and concern they give than from the love they receive.

5. "I must be in control of my emotions and actions at all times or I am weak and worthless."
Problems with This Way of Thinking:
--No one can be in control at all times. This is a myth perpetuated by Hollywood heroes in action movies. We cannot live our lives according to a Hollywood script.
--Emotions cannot always be controlled. Furthermore, a person who attempts to have tight control over their feelings has difficulty being spontaneous and having fun. They may also tend to try to control others and so are not much fun to be around.
--A person who has this idea and gets depressed is then likely to get even more depressed because they will tend to blame themselves for not being in control of their situation and feelings.
--Part of the fun of life is being spontaneous and seeing what will happen next in life.

Tuesday, January 04, 2011

The One and Only One Good Thing about Divorce

Therapists generally do not recommend that people divorce.  This is for a variety of reasons.  For one thing, most of us do not consider it our role to make such a recommendation.  In addition, have seen how difficult separation and divorce can be on people.  There are high rates of depression in separation.  Then there are the effects on childen.  And we have seen times where divorce may have seemed to be the solution for a patient's depression or problems, but it wasn't really.  Divorce is not a simple solution for problems.

But what if, despite all that, you are getting a divorce?  What if you didn't choose it, and it was forced upon you?  Or what if you began the divorce process but felt you had no choice?

What is that one thing which is good about divorce?

I believe that it provides a chance for re-inventing oneself.  We have all gone through our lives trying to make the puzzle pieces fit as best we could.  But it is a little like a 12 year trying to build a house or car.  They reach their 20's and would like to make some changes to their house or car, but they would practically have to level the house or take the car totally apart to do it.

Divorce is like a card table with a jigsaw puzzle with a bomb underneath it.  The bomb goes off, and the puzzle is once again thrown into pieces.  Not everything has to be put back together.  But quite a bit has to be reassembled.  And this time there is the opportunity to reassemble one's life in a better way than it was put together before.

Of course, I am speaking somewhat optimistically, pointing out the opportunities for growth.  I often see my patients going through a growth process like this.  Unfortunately, it can also be true that people may simply put the puzzle back together just as it was before.  Maybe a woman keeps looking for her worth in sexual encounters with men.  Or a man continues drinking and looking for his worth in money and status.  But there is the opportunity when relationships break up to stand back and do something new with one's life.  Whether remaining single or getting back into a relationship, routines will be disrupted, and new routines have to be created.  There is a chance also for taking a new look at one's religious and philosophical beliefs.  There is a chance to make new friends.  It can be an opportunity for learning new leisure interests.  Perhaps a new dating partner likes skiing, or opera, and you learn to like them too, even though you thought that you would be interested in them.

As painful as divorce can be, if you find yourself going through it, this one good thing about it needs to be understood and taken advantage of.  Take the chance to do something new and better with your life.  Seek out a therapist if you need to in order to use it as a growth process.  Use your adult perspective to redo old decisions from childhood which were not working for you.  There may never be an opportunity like this again in your life.

Monday, January 03, 2011

What Does Psychological Testing Have to Offer Me?

Most people never need psychological testing.  But since I do a lot of it, I am very aware of what it can offer to people.

Most of the time it is a psychiatrist who is requesting the testing.  They are wanting more information about diagnosis. People are in psychiatric hospitals for only a very short time these days, so the psychiatrist is in a hurry to understand as much as possible as quickly as possible--"Is the person depressed;" "Are they in touch with reality;" "what is is their IQ?" and so on.

Sometimes it is the client that needs information.  Perhaps they need to document their symptoms for one reason or another, such as applying for disability.  While psychological testing is not necessarily the same thing as documenting a disability, testing reports do provide useful information about symptoms, and they also help to pull together a lot of relevant information about a client's history (symptoms, hospitalizations, effects of symptoms on work, and so on).  Creating a total clinical picture and history to present in applying for disability is difficult for many patients, because of their psychiatric problems.

Another leading reason for testing these days is establishing the diagnosis of ADHD.  Family doctors may be reluctant to prescribe ADHD medicines without a full evaluation.

Diagnosing the onset of dementia, or Alzheimers (Alzheimers is a subset of the dementias) often necessitates testing.  People may think that they have memory problems but really don't.  Or people may not believe that they have cognitive problems, but their family members do.  Psychological testing is an objective way of answering that question.  When a person is in the early stages of Alzheimers, there are medications which can help, and so it is important to know when the onset of dementia is occurring.

Neuropsychological testing is aimed at establishing how well the brain is functioning.  It is used with dementia, but it may also be called for after motor vehicle accidents, strokes, and diseases of the brain.
Oftentimes, children are having academic problems, and it is not clear if the problem is intelligence, ADHD, learning disability or some emotional issue.  Testing is often helpful in this situation.
Sometimes children are having behavioral problems and it is not clear if there is a serious disorder present, or whether they are just "going through a phase," or simply responding to stress within the family system.

These are some of the typical reasons that I receive requests for psychological testing.  I enjoy testing because it allows me the opportunity to interact with almost every conceivable type of patient.  Moreover, it allows me to provide a little bit of consultation as well as helping to establish the diagnosis.  In other words, I don't just test the person and write a report.  I like to interact with them and help them develop strategies for dealing with their problems.

Sunday, January 02, 2011

More On Aspergers

Since the Asperger's article was one of my more popular postings, I am saying more about that here.

Let's look at each of the DSM-IV criteria and try to understand them the best we can.


A. Qualitative impairment in social interaction, as manifested by at least two of the following: 

1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction;

The issue here is whether the child can participate in social communication, not just using words but using the eyes, hands, and whole body.  Poor eye contact can be a tipoff to a problem in this area, but the criterion says that there has to be a deficit in multiple nonverbal behaviors, so poor eye contact alone would not be sufficient to meet this criterion.

2) failure to develop peer relationships appropriate to developmental level;

Aspergers children seem to prefer the company of adults or younger children.  Adults may be preferred because the language used among them is more "objective" and intellectual.  Children of a younger age may be preferred because the Aspergers child has not progressed developmentally as much as their age mates.  Communicating with age appropriate peers requires a high level of social skills.  Moreover, with one's peers there is always a type of competition for social status, or at least for inclusion, and the Aspergers child is not able to keep up in that competition.  They don't have to compete with adults, and they can compete more easily with younger children.

3) a lack of spontaneous seeking to share enjoyment, interests or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people);

The Aspergers child lives in their own world to some degree.  They do not necessarily want to bring things of interest to them and show them to other people.  They are happy with discovering things or playing with things on their own.

4) lack of social or emotional reciprocity.

What does this mean?  Well, I can tell you what I take it to mean.  Social reciprocity would mean being able to give help and receive help.  It could also mean playing a game with give and take rather than just playing with toys and games on one's own, or playing side by side with someone.  Emotional reciprocity would involve being caring and empathic for others.  If another person is hurt or feels sad, then most children have some sense of sadness.  If another person has something really good happen, then most children have some good feelings, too.  Again, it's all about whether they are in their "own world" socially and emotionally.

B . Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: 

1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus;

An Aspergers child may be very focused on a normal activity but to an unsual degree, such as knowing more about insects than most adults, or knowing a great deal about racing cars, or video games.  One child was very interested in Pokemon--not unusual in itself.  But he had drawn every single Pokemon character and made two elaborate and well organized notebooks with all of the characters--an extreme investment of time.

Or the Aspergers child may have an interest in something very much outside the realm of most children's interests, such as learning the Russian language.

2) apparently inflexible adherence to specific, nonfunctional routines or rituals;

Sometimes these routines can look like Obsessive Compulsive Disorder.  For example, it might involve needing to have all of one's army soldiers standing up in a row before going to sleep.  Sometimes, this symptoms just looks like an overly strong insistence on routine.  E.g, the child has to put the shirt on, put their pants on, brush their teeth, pick up their books, pick up their lunch, in that order before going out the door.

3) stereotyped and repetitive motor mannerisms (eg: hand or finger flapping or twisting, or complex whole-body movements);

The extreme forms of this are unmistakable, such as hand flapping.  Other times, the child is doing something in a more subtle manner and hiding it from others.

4) persistent preoccupation with parts of objects

It's not the whole object and its associated purpose which may interest the child but some small part. One child in my office was intrigued by the bottom of a brass lamp, which was convex and had a funhouse mirror effect.  Another child played with toy cars by turning them upside down and spinning one of the wheels.  Many Aspergers children like to take things apart.

C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. 

In other words, there has to be some impairment in functioning for the disorder to be diagnosed.  If they meet the above criteria, they are very likely to have some impairment in functioning.

D. There is no clinically significant general delay in language (eg: single words used by age 2 years, communicative phrases used by age 3 years). 

If there is, then a different pervasive developmental disorder may need to be diagnosed, possibly austism.

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than social interaction), and curiosity about the environment in childhood. 

If there is, then a different pervasive developmental disorder may need to be diagnosed, possibly austism.

F. Criteria are not met for another specific Pervasive Developmental Disorder, or Schizophrenia. 

Other Pervasive Developmental Disorders would take precedence in the diagnostic decision making chart.  And if a full symptom picture of Schizophrenia is present, then Schizophrenia is diagnosed instead of Aspergers.

These criteria are being revised for DSM-5.  At that point, autism and aspergers will probably be subsumed under the diagnosis of Autism Spectrum Disorder.  I think this makes sense.  However, it will make my job a little more difficult--telling a parent that their child has Austism Spectrum Disorder.  The word autism carries a lot of emotional baggage with it that the term Aspergers does not. 

Saturday, January 01, 2011

A Note About Emails to Me

Until recently I have not included my email address.  There are some very good reasons for this.  Most of all,  I do not want to be giving therapy advice by email.  There are many ethical and legal problems with this.

But on the other hand, I am glad to provide educational information. 

So I cannot offer therapy or advice.  (It may be presumptuous of me even to think that people might ask for that; but just in case...) 

If you have theoretical or factual information that you want to share with me or questions that you want to ask me, I will be glad to hear from you.

Ed Beckham

Navigating the Maze of Psychotherapy--And Choosing a Therapist

It can be quite a daunting experience to try to choose a therapist.  It would be kind of like me going to Manhattan to choose an investment banker for a company (if I owned such a company).  I wouldn't be able to tell one investment bank from another.  The bankers would all come with impressive offices and impressive titles, and they would have all graduated from impressive institutions.  I would be out of my league.

I'm sure that it must be much the same for individuals trying to find a therapist.  Where to start?

Let's take a look at some of the obvious practical issues which I think influence people choosing a therapist:
  • Are they on my insurance plan?
  • What type of therapy do they do?
  • How much do they charge?
  • How close is their office?
  • How often will they be able to see me?  Want to see me? 
  • How often can I afford to go see them?
These are the practical issues which I suppose influence people in their decision making.  (I don't know if there has every been a study on what really guides people's decision making.  It would be an interesting study for some aspiring graduate student out there.)
Now, here are the issues which I think are most important
  • What is the conceptual framework of the therapist?
  • Will you be able to build a therapeutic alliance with them? (Or perhaps the question is will the two of you be able to built a therapeutic alliance together?)
  • Will you feel accepted by them and be able to tell them about the parts of yourself that you hide from others?
  • How much experience has the therapist had?
  • What is their reputation in town?
  • How "professional" are they?  Do they have good ethics and good boundaries?
  • Are they burned out and tired, or do they still have an energy and zest for what they do?
  • Are they able to see problems in only one way?  Or can they work out of multiple frameworks?

These latter questions are very difficult to answer.  Even colleagues that I have known over the years are still a little bit of a mystery to me because I have never had the opportunity to listen in to one of their sessions.  I know how they come across to me, and I have an idea of their conceptual framework, but I have not actually seen them do therapy.  So if someone came to me asking for a referral, it would still not be a slam dunk process for me to decide whom I would recommend.

But nevertheless, in case you are one of those individuals who has made the decision to seek therapy, here are some ways you might go about it.

Many people start by checking the list of providers in network on their insurance list.  That is not a bad place to start, but it is not the sole consideration.  Insurance companies are getting more picky.  If there have been ethical complaints and lawsuits, a therapist may be taken off their list  So being on an insurance list is one consideration, both ethically and financially.

Check with your family doctor.  They may have had experience with referring to a specific therapist, and they know whom their clients have liked and who they haven't liked.  Similarly, ask a pastor, or ask friends.

Place a call to the therapist's office, saying you would like to talk to them and ask questions.  Notice how long it takes to get a call back.  In some instances, you might not ever receive a call back.  If you receive a returned call the same day, that is a good sign that if you had an emergency they would get back to you.  Now some doctors are really, really busy.  And I am not criticizing a doctor who would not return a phone call to a stranger within 24 hours.  But it could still be useful information for you to have.

Ask questions (maybe some of the ones above).  You're not exactly looking for an exact set of answers.  You want some idea to the above questions, but you are also listening to the tone of the person and asking yourself whether you might be comfortable with them. 

Are they defensive about you asking questions?  Or do they take it in stride?  Do they seem sure of themselves?  Unsure?  Cocky?  Dogmatic?

You might also ask if the doctor would be okay with you seeing them a few sessions and then deciding whether to stay in therapy with them.  Again, it's not their exact answer which matters.  It's the way they handle the question that gives you the most information.

So, good luck.  Remember, you know more than the therapist about some things (such as what is going on in your life), and they know more than you do about some things.  So don't be afraid to dialogue with them and ask how it is that they can go about helping you.  Have confidence when you talk to the therapist, and if they make you feel intimidated, well, maybe you need to keep looking.