I moved to Seattle to renew my life, yet I’ve been as depressed as ever. Shouldn’t I be less vulnerable in a beautiful place like this?

Answer:

I encounter people in this situation regularly. Seattle is a city of transplants, and the adjustment is not always quick or easy. Here are several reasons we could designate a special “Seattle depression” for newcomers in the the Emerald City.

First of all, moving sucks. You may have escaped a messy family situation and a doomed marriage, a rotten job and hell-hole physical setting, but you’ve come to a place where you don’t know many people. Isolation correlates with depression. Often, being with irritating people who you know may still better for your mood than being alone. Seattle has a reputation as a place where people are generally insular and hard to get to know. Whether or not the reputation is deserved your feeling blue and insecure will not help your efforts to integrate.

But I’m an introvert, you may say. People are a pain, and I like to be alone! Just the same, being human, you have tribalism in your genes. You don’t have to change you personal nature, but you might benefit by adjusting your patterns of affilliation.

Besides the isolation that comes with moving, you have disrupted your usual routines. Routine is good for your mood, plain and simple. Humdrum activity is still activity. It gives a sense of purpose it keeps you in motion and it lends structure to your day, whereas now that structure may be hard to come by.

The reduced light that comes with our long winters is undeniably a factor in depression, but an overblown one in my opinion. The problem with winter is not just the reduced sunlight but the fact that we don’t move around as much. Physical activity is good medicine for depression and it just doesn’t come as easily in the Seattle winter.  If you get a boost from taking walks in the summer, get a good parka and don’t let the went winter stop you.

All the disruption, lack of routine, reduced activity, seperation and isolation contributes to a sense of anomie – a breakdown in the usual social norms and standards that give us a sense of regulation, stability and belonging. Even a slight sense of dysregulation and weakened structure adds to anxiety.

As I have mentioned several times before, depressed people ruminate to try to find answers. Ruminating is a vortex. It gives the allusion that we are seeking answers when in fact we’re moving farther from solutions.

You can place all blame the nature of the city if you wish.  But if depression is the fault of this locale, we would have a measurably higher rate of depression.  We don’t.  Incidentally, the only city with a measurably higher rate of suicide is Los Vegas.

So what is to be done? As Mark Twain stated, “It takes a heap of livin’ to make a house a home”. You may need a plan to direct your activity more productively, to find more connection, gratification and pleasure, and tune your thinking to be less depressive. Then, you can begin feeling like you belong, perhaps even like it would be depressing to leave. CBT or cognitive-behavioral therapy is a practical way to do this.

Can you explain to me why it helps with post-traumatic stress to revisit the upsetting event or scene?

Answer:

Can you imagine a cowboy getting over a fear of horses by talking about it in an office?

When we’re in the midst of the horror of a traumatic event, our bodies are thrown into a high state of overdrive. This fight-or-flight response instantly puts the body into just the right mode for survival – battle-or-bolt. We need this arousal reaction – it’s very handy for self-preservation, not to mention the survival of the species. But, it has some disadvantages.

For one, it is easy to get too trigger-sensitive. That is, the merest hint of danger may ignite you. Say, a combat vet hearing a sudden noise, or a rape victim approached by a gentle man just a little too close and quickly. Both of these otherwise calm and poised individuals are instantly pitched into the same dreaded state.

A second disadvantage is that this fight-or-flight just shrieks. It’s terribly uncomfortable and we’ll do almost anything to avoid it. It’s supposed to be uncomfortable by the way. Is there any smoke alarm which gives a comforting little melody? The discomfort puts us on high alert, and trains us to avoid dangerous situations where we might experience the punishing sensation.

Finally, just as we link the “shriek” of the full-throttle fear response to the presence of danger, we also link danger to the response. Pavlov’s dogs hear a bell, therefore, they assume, it’s chow-time. It’s as if we say “I feel like there’s a grave danger, therefore, there must be a grave danger.” The sense of impending doom causes panic, which increases the sense of doom, and through the roof we go.

Now, you can read many books about post-traumatic stress disorder. You can talk with friends and therapists at length and you can perform rituals complete with incense. Actually these things are important – the support of friends and family, a sense of belonging, comforting rituals, a consistent structure to the day, a sense of purpose and meaning in your work and so on. Elements like this in your day-to-day life may prevent a traumatic event from shaping into post-traumatic stress disorder, or may soften PTSD and hasten its resolution. But the instant, patterned reactivity of PTST is in the gut, so to speak, and might remain untouched. In this case, you have to have the bodily experience, in a perfectly safe situation, to “unlearn” the reaction.

Think of the cowboy who’s been thrown from his horse. He can stay away from horses and feel just fine. He walks up to a horse though, and panic wells up. If he’s sensible like I am (or, uh…try to be), he’ll walk away from the horse and instantly feel better. But what just happened? The lesson is “close = danger, and distance = safety”. This has just confirmed to him that the horse is indeed hell-bent on killing him. He feels good for the time being, but has strengthened his PTSD.

Let’s go to the rape victim. She might stay away from a two-mile perimeter of the crime scene, she might avoid unknown men and will avoid imagining the awful event. Then she sees a therapist, who in this case is a little like the dentist in that he or she has to create discomfort to be effective. After plenty of preparation, and when the victim – wait – she was a victim. Now we’ll call her a client. When the client can pronounce with confidence that the office is in fact perfectly safe, she might be instructed to tell the story of the rape. In the present-tense, with detail. In all likelihood it will bring on that old terror. Almost like she’s there. “I feel like there’s grave danger, therefore… hey!” This time she sees that she is alive, safe and intact. She has started to learn, experientially, that she can afford to disconnect this particular alarm.

I’ll leave out other details of the process but if she repeats something like this often enough, very soon she’ll find that the retelling sparks less and less of a reaction. Keep going, and it will become downright manageable. She’ll be instructed to go out at night to safe places with safe people, and so on, to “desensitize” outside the therapy office in the same way.

The trauma happened in the past. Revisiting is not re-experiencing; it just feels like it. But feelings cannot harm you. Saddle up.

I want a therapist who likes me. Therapists I’ve had in the past seem to just seem to want to to want to get me in and get me out. Or, they’d treat me like a child, using pity and patronizing. Another one was young and inexperienced and seemed awed by me which wasn’t helpful, and I imagine others are remote and analytical, too removed.

Answer:
As a therapist it’s something of a duty to find a way to like everyone I’m working with. But of course, it’s a complicated task. No one is likeable or dislikable at all times, and I myself have moments when I seem to hate everyone (not in the therapy office, luckily; it’s when I stub my toe badly). Also, “like” has different components, all of which vary in degree with different relationships. There is admiration, compassion, curiosity, attraction, shared values and so on.

To a large degree, it’s harder to like someone who I cannot get to know, and easier to like someone the more I can get to know them – and by this I mean not just their story and worldview, but their feelings as we interact.

But it’s a two-way street. If I may be so blunt, you have a role to play in how a therapist responds to you. I would not want to promise to like someone who doesn’t earn my fondess, and I would do you no favors by giving unearned appreciation. What I can do, over time as we build a relationship, is give direct feedback on those things you do which are likeable, and those that may elicit negative reactions. Our feelings toward each other can be a window we both utilize.

I want you to be someone who can be liked by your therapist – and the others in your life.  We’ll work on it.

Why wouldn’t I want some intensive, ongoing therapy, which will instill change on a “deeper” level?

Answer:

First, it is worth mentioning that time-effective is not necessarily the same as short-term.  There are many instances where we decide to spread out the frequency over time, meeting every other week or monthly, for instance.  Also there are a few people I see every one or two weeks over the course of a long time.

Overall, my analogy with goal-directed, time-effective therapy vs. the more ponderous approaches is that you can take a drive to a destination in two ways. One would be to take the long, winding scenic road and the other, a strait superhighway. Both will get you there. The long road will allow you more fascinating views, maybe some exciting twists and turns and possibly some long tedious stretches. The problem is, you pay as you go and the cost will add up. Also, you may find in the future that you have strayed away from where you want to be, and you will not be able to retrace the route. 

The superhighway gets you there more efficiently. It is cheaper. Quicker. Uncomplicated. If in the future you need to make movement again, you will remember the route and can take it on your own, or with a little more brushing up with the therapist.

If I allow myself to get cynical I would say too that there is too much potential for a conflict of interest. In other words if you get well, your therapist loses a golden goose. I fear that analytic therapy can often foster an unhealthy dependence. It has also fostered systems of analytic theory that are far too complicated, inherently unverifiable and rarely effective. The poster boy for this view would be Woody Allen (as he is often portrayed), a lifetime psychoanalysis devotee and just as neurotic as ever.

So, I try not to be too cynical. I know that there are many wise and effective analytic therapists with many satisfied clients. It is a perfectly good direction to go in, though not with me.

I hear some therapists referring to their clients and some refer to their patients. What am I?

Answer:

Alright, I confess.   I only dream of being asked this question, and I planted it. See, the two terms highlight an interesting evolution in my field.

Long ago, sparse treatment choices included couch-and-cigar style psychoanalysis, stark hospitals and crude medical procedures. The practitioners in the field were physicians, and this made you the patient. Now, seeing me, you are a patient again. Here is how this happened.

Starting in about the fifties, you would have become a client. At that time there was a reaction against the “medicalization” of mental illness. We wanted to remove the stigmas surrounding the field. We wanted to normalize everyday neurotic concerns rather than to view them as a disease. Behaviorists persuaded us that we could view our concerns in terms of what we had learned, and that therapy essentially was to be instructed in better ways. Many wanted to point out that social and economic inequities were at fault for much of our misery, and that to blame the individual was to compound the broader problem.

There was the need back then to take the field from the sole ownership of MD’s and spread it around to psychologists, social workers and counselors, in part to make therapy less mysterious and more accessible. Therapy became a more egalitarian, collaborative process, and in those days “doctor and patient” implied a more directive, hierarchical set-up than it does today. Also, the therapy office needed to be perfectly private and removed from your usual surroundings, so that you could feel safe enough to open up about matters kept confidential from your physician. Finally, many thought that to prescribe medication, or to focus much on behavior, was to ignore the workings of the unconscious and the deep complexities of our inner lives. Putting aside this last item, I do still hold to the ideas above, generally speaking. But they don’t hold the gravity they used to.

In the nineties, the pendulum began swinging back. Why? First there is recognition of the fact that a small percentage of those who experience mental illness ever see a therapist. Most do, however, see a primary care doctor. A great percentage of complaints brought to doctors, including back, chest and abdominal pain, headaches, fatigue, insomnia, dizziness and so on often have no apparent physiological cause. Psychology, environment and behavior however relate closely to all of them. Stress and life satisfaction levels have a huge influence on the impact of physical disorders and on the outcome of treatment, and are beginning to get the attention they deserve in the exam room. For most, the few minutes spent discussing these matters in the doctor’s office are all there is. Physicians are de-facto therapists.

Another change is in the fact that we are chipping away at the perceived wall between the body and the mind, between physical and mental health. The distinction between the two is so small and so fluid that it is not particularly meaningful. The details here deserve another discussion but consider this: The quality of our health and the duration of our lives may not have much to do with medical care. Setting aside economic forces, and environmental factors such as pollution and social ills, the biggest factor is our own behavior. Obesity, heart disease, diabetes, addictions, injuries and in many ways even cancer and communicable diseases, are prevented, and perhaps treated, more by our own behavior than by any medical interventions.

In therapy, your level of physical activity and social connection is one of the better predictors of a good outcome. Often, a solid exercise program can get a better result for depression than counseling does. Therapists now routinely inquire about chemical use, exercise, sleep, nutrition and other aspects of physical self-care.

You might ask, “Apart from all of this, if I’m a patient, the implication is that I’m sick, isn’t it? But I don’t want to be considered sick just because I’m getting therapy.” My response is, “sick” or “not sick” is hardly relevant. I see some unfortunate people who have no problem viewing their mental health condition or chemical addiction as a sickness. Also, I am a patient any time I see a doctor for a physical exam or to treat an injury, and am not concerned with “sick”.

Few of us would want our personal physician to overlook our emotional well being, or to ignore a component as important as our behavior and emotions. Neither would we want him or her to be cut off from the medical specialists we might need. Why then, would we want our mental health work to be separated out?

Our recognition of all of this is leading to more integration between the fields. Patients tend to be more satisfied when care is integrated, and overall costs can be lowered. But to do this, barriers need to be overcome. One such barrier is the need for strict confidentiality. Mental health records have tighter privacy safeguards than do medical records. The records cannot be fully combined, but the advent of electronic records allows for strong safeguards while eliminating the need for a complete schism. Another barrier is in the fact that the different fields use slightly different languages. The term behavioral health has emerged as something more useful to the physician, and it can combine the mental health and chemical dependency fields (there is another rift to discuss another day). Finally, there is of course the word for those receiving care.

This can all be summarized like so: I deliver care in support of your overall wellness. This makes me a health practitioner, and it makes you a patient.

Why aren’t you a “preferred provider” with my insurance company?

Answer:

I try to keep my practice independent of the insurance companies for several reasons. I want to be free of their monitoring. I also like to be free of their restrictions on the number and frequency of sessions and the conditions that can be treated. I want to know that my clinical decisions cannot be affected by an outside business, and I prefer the higher level of confidentiality when all my information about you stays within my office.

I am well aware of the downside for some clients who must pay from the pocket as a consequence, or accept a lower rate of reimbursement when they submit my out-of-network invoice. On the positive side, in addition to keeping mental health records from potentially affecting future insurance decisions, you too are free of the restrictions imposed by the insurer.

Finally, my style of practice is such that many are able to find resolution early, meeting their therapy goals relatively fast. I know that when payment is coming from an outside source, therapy is more likely to drag on for as long as the reimbursement is coming in.

If my fee is a barrier that would keep you from coming in, call me.