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Hey! Are you okay?

Hi! I’m okay. I’ve been away from the blog for a bit because I was dealing with some health issues, and then just having a hard time in general and really needed some R&R, and then needed to catch back up at work. But I’m here! Thanks for checking in on me :)

Do you have any experience with depressed patients that are being treated with a combination of SSRIs and medical marijuana? is that something that a psychiatrist would ever recommend? If not, are there any related asks you could link? thanks! hope you’re staying home and healthy.

Medical marijuana isn’t approved for depression or any other mental health disorder. There isn’t enough research to prove it works generally. Mostly, marijuana and derived products like CBD are used to prevent seizures, treat nausea, and encourage appetite. So no- a psychiatrist would not prescribe medical marijuana for depression and IMO would be unlikely to recommend a patient buy marijuana on their own for that purpose. Marijuana is a complicated psychoactive substance that has pros and cons, so if there was ever an FDA-approved treatment for depression, etc., I think it would be a derived compound and not the plant as a whole.

and thank you! hope you are staying well too.

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Hey, do you have any links for ending therapy? I’ve been going to session for the past four months and I’ve kinda noticed that I don’t really need it anymore. Thanks!

Here are a couple I found: 1 2 3

if you search “termination” on my main page you should find more. Congrats on your progress in therapy!

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Hi! I'm a therapist who has been working on deepening my understanding of grief and bereavement to better support my clients. I wonder if there are any books you would recommend? I've already got 'Staring at the Sun' by Irvin D. Yalom, 'How we Die' by Sherwin B. Nuland, and 'Healing Pain' by Nini Leick and Marianne Davidsen-Nielsen. Keep up the good work!

Hi anon!

I would recommend some memoirs or lived experience type books to supplement so you can understand more deeply how grief impacts people, and how it can vary. I like:

When Breath Becomes Air by Paul Kalanithi

A Grief Observed by CS Lewis

Wild by Cheryl Strayed

Eleanor Oliphant Is Completely Fine by Gail Honeyman

A Man Called Ove by Fredrik Backman

Oh, and if you haven’t read it, I think Man’s Search for Meaning by Viktor Frankl would also be really helpful.

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what would you do if you had a situation with a client where significant communication barriers were preventing any progress in therapy? say you had a client where week after week, it is just unsuccessful attempts at explaining their symptoms, behaviors, thoughts, insights, reasonings, etc. etc., but when you try and put it into your own words to see if you understood correctly, they say “ehh, not exactly” every time, and therefore cannot move forward in treatment. or say you had a client who interprets things you say drastically off the target—none of what you say seems to get through to them, it seems like theres a magic circle sitting between you two, reshuffling everything you say to them—and you have no idea exactly what messages they are receiving from you, nor any idea what they are really thinking from their spoken or body language. what are some possible routes you might take in similar situations to those?

I would talk to them about it explicitly. When there are issues in therapy like this, the therapist can try and solve it alone- and sometimes that works -but often it’s most helpful to just discuss it with them, see what they think, and figure out a solution together. Some of the potential solutions might be more drastic- like transferring to a new therapist, or getting an assessment done if it turns out that the client has this issue with a lot of people -but it could also be fairly minor (e.g., maybe the two come to an agreement about ways to understand each other better and communicate more effectively).

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Have you known anyone who applied for clinical psychology PhD programs more than once before getting in? If so I would love to know more about how they navigated reapplying to/interviewing at the same schools. I am slightly embarrassed to say that next fall will be my third time applying (I haven’t been in my lab position long enough to feel good enough to apply this round) and I know others who are applying for at least the second time as well who would appreciate any advice. Thank you so much!

Hi anon,

Sure! It’s not uncommon to have to apply more than once.

If you applied to a school and did not get an interview, I wouldn’t worry about needing to address that you applied before or change your materials in any way. That’s because the committee will probably not remember you (sorry) and there’s no reason to spend your valuable personal statement space discussing it, etc. This is especially true in situations where you think you were probably cut early on in the process- like due to a low GRE/GPA or very little or no research experience -because then the committee would not have read your first set of materials in detail.

If you did interview at a school- or have other reason to believe some of the faculty will remember you, like maybe you talked to a faculty member you were interested in working with via email or phone, and they were responsive -then you do need to address it. But you don’t need to make a big deal out of it. I would: A) have your letter writers address in their letters to those schools, and highlight how much you have achieved and grown since your last application; and B) address it briefly in your personal statement, again focusing on your growth and why you believe this school continues to be an excellent fit. So very positive and growth-oriented.

If you did have some kind of connection/relationship with a specific faculty member- like you interviewed to work with them -you may also want to email them ahead of time to tell them you are interesting in applying again to work with them, highlight your new experiences (briefly!) and gauge their interest in that. Again, growth-oriented here, no negative comments about yourself.

I hope that helps, and good luck with your applications!

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i think i remember you mentioning that the difference between avpd and social anxiety disorder is just that avpd is more severe, but couldn’t someone have avpd but not have any symptoms of social anxiety? is that really the only difference?

(here’s a post anon might be referring to- excellent memory, anon!)

A person with avoidant personality disorder (AVPD) has to have social anxiety- it’s really the key part of the disorder. Both disorders are primarily characterized by severe anxiety about social situations, and particularly worries about being judged, humiliated, or rejected, and that anxiety leading to avoidance of social situations. Severity is the primary difference between the two- for example, people with social anxiety disorder can often identify that their anxiety is not rational- that other people are not likely to be cruel or rejecting even though it feels that way -while people with AVPD often can’t identify that. AVPD is often more expansive too- impacts more aspects of social life and is more chronic. But that’s one of the reasons why it doesn’t really make sense to have both diagnoses (since social anxiety disorder can also be “severe” and long-lasting). Social anxiety disorder can occur with or without panic attacks, and people with AVPD do experience physical symptoms of anxiety, so that’s not a differentiating feature either.

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PhD in psych Anon from a few weeks ago again 💕thank you for the encouragement, you asked for an update :) working on self care and sleep, professional boundaries with colleagues/supervisors, thesis and dissertation planning, I have seen my first clients and am definitely feeling all the imposter syndrome and literally loving reading therapy books lol, any recommendations ?, how are you, what have you been up to?😊

Hi anon, thanks for the update! All that sounds very in line with what I was dealing with too- and good for you for prioritizing self care and sleep, it is essential!

One of my favorite books about therapy is a memoir- Buddha and the Borderline by Kiera Van Gelder. I also like Bad Therapy: Master Therapists Share Their Worst Failures- so important to understand what bad therapy looks like, not just good therapy, and to know that no matter how experienced you are, you’ll still make mistakes. Also, if you haven’t seen Never Have I Ever on Netflix, I recommend it- one of the few times a TV therapist appears to be doing a good job.

Things are okay over here, much calmer than earlier in the pandemic which is good. I’m still super early in my faculty position and have tons of things to figure out, but have fortunately found that most of the people around me are welcoming and helpful. I’m really enjoying my research, clinical work and working with mentees. So much to do though!

Can you explain how you drill in to a problem, such as overeating or lack of motivation, using the DBT technique of behavior chain analysis?

Note: Chain analysis isn’t just DBT, all the behavioral therapies use it!

So essentially what we are doing in chain analysis in understanding the chain of internal and external events that lead to an outcome, which is often an emotion, a dysfunctional coping mechanism (like self-harm), some other kind of undesired or harmful behavior (yelling at your partner), or another symptom. However, it could really be anything (including something positive)- but usually in therapy we are doing it to identify what events occur that lead up to something harmful or undesirable.

Remember that we are interested in both internal and external events: so, this includes thoughts, emotions, behaviors of the person, things other people do, environmental factors, etc.

So typically we start with the outcome, and look at a very specific event- not “in general.” Let’s say the outcome is a self-harm behavior. So we’d look at what happened right before that behavior occurred- like in the seconds to minutes range. This first chain is usually a feeling, thought, or behavior by the person (so not external). Then we’d look a little further back- what led to that feeling or thought? And so on. We create a timeline of events until we come to a natural end, and can see the start of the chain that began the metaphorical dominoes leading to the self-harm. That way, we understand one example of what happens in the lead up to something we want to change, reduce or remove, and can find points to intervene at. We can also look at what happens after the event- what the short and long term consequences are, including positive, negative, and neutral, to understand how those might impact future events.

Here’s an example of a chain (trigger warning: self harm)

New person I’m dating cancels dinner plans because they have to work late

⬇️

“They don’t care about me. They’re going to take me for granted like everyone else.”

⬇️

Think about past times people I love have hurt me

⬇️

Feel sad, angry, resentful

⬇️

Call new person back but they don’t answer

⬇️

“This is proof they don’t care about me.”

⬇️

Angry, vengeful

⬇️

Leave long, angry voice message to new person

⬇️

Feel shame, regret

⬇️

“I’m going to be alone forever and it is my fault”

⬇️

Feel shame, sad, angry at self

⬇️

“I deserve to be punished”

⬇️

Urge to self harm

⬇️

Prepare to self harm (gather materials etc)

⬇️

Self harm

Short term consequence (of specific event only, not entire chain!): relief, numbing, fatigue. some kind of harm depending on self-harm activity. [varies of course based on person and specific harm activity]

Long term consequence (of specific event only, not entire chain!): shame, regret, sadness. could result in long-term health impacts. [varies of course based on person and specific harm activity]

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do you think its far-fetched to say that it may be impossible or near-impossible for someone to really access the benefits of therapy if they suffer extreme impairment in their ability to connect with and relate to other people? say Person A has a presentation of a mixture of personality disorders, for example including avoidant, schizoid, narcissistic, and borderline PDs, which undoubtedbly impairs their ability (1/2)

“to connect. i know that in order to really benefit from therapy, a crucial element is finding a therapist you are able to connect well with, and i hear many people recommend to keep searching until you can find one you do connect with, but what if Person A can’t find anyone they can connect with due to their relational impairments in that area? (2/2)“

the reason that the therapeutic relationship is so essential for many people is because it’s important to those people, and having connection and support is healing in itself for those folks. relationships where there is not a feeling a rapport and closeness and support would not be as effective, because those elements are such a big part of what that group of people are looking for.

however: not everyone is looking for that, wants that, finds that important, or finds that easy to create. AND: not everyone finds that essential to be able to benefit from therapy. AND “therapeutic relationship” doesn’t always mean the sort of close, warm, sweet relationship that I think people think of usually. A well-connected, good therapeutic relationship can also be between two people who are more... not cold exactly, but distanced and professional and getting the job done.

For folks who either don’t want that close therapeutic relationship, or struggle to find it (both could be common in your example Person A), one option would be to reconceptualize what therapy includes and what type of relationship they are looking for. A strong relationship can be one that isn’t super warm, as long as the therapist and client work well together. That can mean that they: listen to each other, work together to identify what goals to work on, respect each other’s opinions even when they disagree, etc. (So, things that should be happening anyway).

The point being: the point is that the client is able to work towards their goals in therapy, and the therapist facilitates that effectively. The therapeutic relationship is just one way for that facilitation to happen, and it’s more important for some people than others. It’s fine to be less connected to a therapist, or for the connection to be more formal or distant if the work is still happening.

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thanks for answering my question and running this blog :)

i hope you have a lovely week filled with really really good days 💜

you’re so welcome! hope you have a great week too 💛

has a client ever challenged you? like as a person? challenged you to grow and be uncomfortable with stuff that was happening in your own life? like they called you on your shit instead of you calling them on theirs?

I think you mean this as all one question, but the answer varies for me depending on which part I am responding to.

basically: yes, I have been challenged by clients and grown as a person as a result of working with them. but: no, it was not a result of them calling me out.

I’m gonna expand on this, but in reverse order. usually when clients “call me out” it’s not about a growth area of mine. it’s them being inappropriate in some way- most typically, misogynistic, for me. (I imagine for therapists of color there’s a lot of racism in those interactions). So for example, multiple male clients have told me I wasn’t qualified due to my gender (sometimes in combination with my age- this has decreased as I have gotten older/post-PhD). Others have said that I am only at work until I find a husband and therefore am not invested in their wellbeing. They may criticize my appearance or my voice, etc. These are not criticisms that I am interested in engaging with for growth purposes. They are inappropriate behaviors that either the client needs to stop, or we have to stop working together.

When clients do challenge me explicitly- “call me out” -in a way that is appropriate, it has always been about professional stuff and not relevant to my personal life. So for example, when I’ve had ruptures with clients and clients tell me their perspectives, share their frustrations with me, tell me what they want to happen differently in the future, etc.,- those are important things, and I listen closely to them, and work on them with that client and think about how to apply them more broadly, but they don’t really apply outside of my professional life. Usually they are too specific to my work setting- like, how to coordinate more effectively across the interdisciplinary treatment team, etc.

I think it’s possible that those situations could apply, but they never have for me. However, in general a client would not know me as a person well enough to be able to call me out- they only see me in that work context, and although we get to know each other well, if I am doing a good job, there will be appropriate boundaries up to prevent them from seeing anything outside of that context.

But more generally, the process of working with clients, both when it goes well and when it’s difficult, provides lots of opportunities for growth. As a clinician, ideally you’re always trying to understand how to do better. I’m a very growth-oriented person anyway, but I think being a clinician and being in school for so long has really oriented me towards the idea that all experiences help you grow and learn, and that that’s a really positive thing. So I am challenged and learn from and grow from basically all my clients. Some more than others, for sure- especially if some aspect of the work we are doing is new to me, or the dynamic we have is different and I need to figure that out, etc, but regardless there is always learning happening. There are lots of therapies I have now done many times, like CBT or CPT, but when you work with a new person you need to understand them and adapt your approach to them. So I think there’s the learning you do from individual clients, but there’s also the learning that happens from being a part of the process- like, understanding concepts like balance, flexibility, grace, acceptance, etc- those are thing I learn and continue to learn and grow from because they are natural parts and challenges of the work.

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therapy101

a quick note on what it means to be “ethical” in psychology:

many of you write me messages asking if a specific therapist or other provider was acting ethically. much of the time it’s clear to me that you think the answer is “no” and you’re hoping I will support that.

the thing is, being “ethical” is not about being “good” or “correct” or “talented” or even “helpful.” A psychologist may fuck up big time and not have violated any ethical standard. So sometimes your therapist might offend you or speak in an invalidating way or suggest a technique that doesn’t work or misdiagnose you or any number of things, and they might still be acting ethically. Being ethical doesn’t mean being perfect, it means upholding a set of guidelines to uphold the integrity and intention of the field (in this case, psychology). mistakes are allowed, malfeasance is not.

The criterion that emotional abuse has to have a negative impact on the child—why aren’t other types of abuse held to that same criterion, but rather just emotional abuse? For example let’s use physical abuse in cases where there’s no physical injury, say an isolated incident of spanking, and say it also did not negatively impact the child—why would a case like that be automatically mandated for therapists to report even if it may not have had a negative impact, whereas its okay for certain select cases of emotional abuse that may also not have had negative impact to not hold that requirement of a mandated report?

I don’t know, that’s a legal regulation, not a psychological one. My guess would be that the legal bodies who created these rules didn’t want mandated reporters to report every time they received a report of a negative interaction between a parent and child and didn’t want the law to reflect an idea that a parent yelling, etc., was necessarily and always abusive. While they may want to know about any reports of physical abuse so that they can investigate whether or not it constitutes a pattern, or at least have each incident on record in case it does become a pattern. But that’s a guess.

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Basically wanted to ask the same question as in post 190221041108 on your blog, so I'm curious... If only direct/indirect experience of/threats of violence can cause PTSD, then, what explanation is there for people having such symptoms for other events or series of events? I was betrayed and bullied by a close friend (sounds silly, ik), and the effects are a whole nother thing separate from my other mental health issues. Is there any other "trauma" disorder that isn't specific to death/violence?

“(Continuing from previous ask on trauma) Is there just no concrete research in this area? I see some other people with similar experiences to mine calling it "trauma" but I don't feel like I have a right to that when it's not. Doesn't matter, just wondering about why it seems like only death/violence or intimate partner abuse gets talked about as traumatising? (As in, causing a seemingly concrete disorder that's not just depression or anxiety) Can one "have trauma", as a disorder, but not PTSD?”

(this is the post anon is referring to).

There are a few issues happening here. One is that the diagnostic system is flawed. The PTSD diagnosis, while in some ways better than some other diagnoses in terms of its validity*, still has its own issues- including this cut-off about what “counts” as a traumatic event. But we know that different people experience events differently, and for some people a given event will be traumatic, and cause trauma symptoms, and for others it won’t, and how severe or impactful a potentially traumatizing event is will vary by person. So that’s really a flaw in the DSM/ICD/etc, where those systems are trying to be clear about what they mean by a traumatic event by identifying what most often cause PTSD symptoms (but don’t always), but that means that they exclude events that more rarely but still can cause PTSD symptoms.

The other thing is that we have this language problem, where “trauma” means a lot of different things: the event itself, the symptoms caused by the event, and the diagnosis. So then we have this confusing conversation that’s something like: well, how can I have trauma symptoms but not have the trauma diagnosis because my trauma event doesn’t “count” for the trauma diagnosis? (a lot of the asks from y’all are something like this). and that’s a very reasonable question! this again is partly a diagnosis problem, but one thing to remember is that a person does not need to meet criteria for PTSD or any disorder to have experienced a trauma or to be impacted by that experience. It is in fact common for people to experience trauma, and be impacted by it, but not meet criteria for PTSD. To some extent it’s unfortunate that PTSD is named what it is, because it can make folks feel like everyone who experiences trauma has PTSD and that’s just not true.

The other trauma diagnosis is called “other specified trauma/stressor-related disorder” (I know, very catchy)- it is a sort-of catch-all diagnosis for trauma and stress related diagnoses that don’t meet criteria for PTSD or adjustment disorder or acute stress disorder. Theoretically someone with a trauma that does not meet criteria A could be diagnosed here. It’s also possible- like you mentioned- for someone to experience trauma and as a result, meet criteria for any number of diagnoses including depression, GAD, etc. These are still “trauma” diagnoses in that context because they were caused by trauma even if it’s not in the title. (Again, I think the DSM made a mistake calling PTSD “PTSD” because it makes it seem like none of the other diagnoses can be posttraumatic, but they totally can).

*when I use the term “validity” about a diagnosis, I only mean in regards to how well the diagnosis has been understood and put together, not in terms of the people who have the diagnosis. Since diagnoses are put together by people and don’t exist naturally in the world, they have flaws. All people with mental health issues are valid and criticism of diagnoses are not criticisms of people.

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Going off the one anon’s question about mandated reporting—are you mandated to report child emotional neglect as well? Or physical abuse such as spanking? Also, in cases of most child physical or sexual abuse, I’m sure usually only one instance is needed for it to require reporting, even if it only happens once, never before and never again. Would it be the same for mental abuse? For example say a parent calls their child fat, ugly, and worthless, but it occurs only one single time, with zero instances of abuse before or after? Or what about in cases of child sexual abuse where no assault occurs, such as unwanted sexual comments? Basically in situations where it’s clear that abuse has occured, but might not necessarily fit into the box of what society tends to consider as abuse? Do therapists actually report in all of these situations if they are mandated to do so?

Yes, we are also mandated to report emotional neglect and physical abuse including spanking. (laws/regs vary by state and certainly by country.)

Emotional abuse has to have a negative impact on the child- so it’s not about the number of times it occurs, but the impact it has. One time is sufficient if the mandated reported believes the child to be harmed by it or is at significant risk of being harmed by it.

Unwanted sexual comments (all comments would be “unwanted” because a minor can’t consent) would fall under emotional abuse or potentially sexual enticement- so yes, reportable.

The purpose of the law is to mandate reporting of anything that harms a child physically or emotionally. The training we receive is that when we are unsure, to report anyway and let the CPS worker decide whether to complete the report or follow through with the investigation, etc. We can also call the line and present a “hypothetical”- basically ask whether a situation is reportable, and if so, move to a report. This is pretty common practice for some of the things you’re asking about if a mandated reported is unsure whether something counts as a reportable act. That way we can check to make sure before violating confidentiality because if it does not fall under mandated reporting law, then it is illegal for us to make the report.

Reporting is pretty common, yes. I think therapists are also very aware that a report of a parent calling a child a name once is not going to cause CPS to conduct a full investigation, or (more likely in my case, as a person who works with adults), reporting abuse that occurred 10 or 20 or more years ago is unlikely to cause an investigation unless there are still minor children in the home (it’s also not always required in these cases). So sometimes there are probably cases where therapists don’t report, but mostly people do unless the report has already been made. We do not have to report on the same event if it has already been reported by someone else. If a CPS case is active, we don’t have to report on ongoing issues (”they are still doing that thing”) that the CPS worker is already working on unless there is a new concern (new type of abuse, new child involved).

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Can you have an anxiety disorder without experiencing physical symptoms of anxiety?

Depends on the anxiety disorder. Yes for generalized anxiety disorder, no for panic disorder, for example. Most people with anxiety will have some type of physical symptoms, but those can vary widely- sometimes it’s those acute symptoms that are common with panic attacks: heart racing, sweating, heavy breathing, feeling like you might pass out, dizziness, etc. But sometimes it’s a little more vague- a sort of sense of restlessness, a feeling like you need to be moving, a jumpiness. Or it can be tense muscles, and chronic pain as a result. People with anxiety can also experience tiredness and difficulty sleeping, which is a physical symptom, and can have impacts on their appetite, or nausea, or other types of GI problems (like depression).

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