Intrusive Thoughts and Postpartum OCD

Don’t feel bad if you’re a mom, medical professional, or mental health therapist and you’ve never heard of Postpartum OCD (Obsessive-Compulisive Disorder). Most people haven’t. The thing is, it’s more common than you may think and it’s important for most everyone to be aware of it. If  more people know about it, then chances are, women and their families will have a better chance at getting correctly diagnosed and treated. Hopefully, they’ll also avoid the uninformed judgements of others. I consider it my mission to spread the word because the women who have it typically suffer in silence and do so needlessly. I assure you, with help, relief is within reach.

Index of topics:

What it is
What it isn’t
Risks for developing it and prevalence rates
Why mothers stay silent
When to get help
A message to moms
What friends and family can do
Bibliography

What it is

There are some women who, after they give birth, experience a typical variety of OCD. They likely had OCD prior to becoming pregnant and, if they had been symptom-free previously, they may find that their symptoms re-emerge with the stresses that commonly accompany the transition to parenthood. Although their obsessions and compulsions can take many forms, one of the most well-known are obsessions centered around germs and cleanliness; they wash their hands until they bleed and fret over the idea that they and/or their children may get sick with something horrible. It is distressing, time consuming, and tiring.

What I’ve described above is what I learned in graduate school and it is the kind of OCD that I had treated prior to my work as a volunteer with Baby Blues Connection (BBC), my local perinatal support organization. While facilitating support groups with BBC, I learned about a variation of OCD of which I had previously been unaware. Many of the moms I saw reported having scary, intrusive, and sometime violent, thoughts about harm coming to their babies. As Karen Kleiman and Amy Wenzel wrote in their 2011 book, Dropping the Baby and Other Scary Thoughts, these thoughts of harm fall into the following categories that frequently overlap with one another:

• Threats to the baby’s physical well-being
• Thoughts of an accident
• Thoughts of intentional harm inflicted by the mother
• Thoughts of intentional harm inflicted by another person
• Disturbing sexual thoughts

Many times these thoughts are highly visual in nature and  some say that it’s as if they see a movie play out in their heads. Women are horrified to have these thoughts or impulses, especially when they see themselves causing the harm. They do not want to do these acts and often go to great lengths to ensure their babies’ safety. They may avoid certain places or activities and install safety devices. They may hire someone else to care for their baby. They may believe that they should not be a parent. Then they worry. And worry. Then worry some more. When they’re finally so exhausted that they fall asleep, they have nightmares about what they’ve spent their day trying not to think about. In pushing the thoughts away, they inevitably make it worse.

What it isn’t

Most all of us, at some point, have had intrusive, horrible thoughts. We imagine something gruesome or perverted, because…well…we’re human and that’s what the human brain will do. Typically, we dismiss that thought and if it does pop up again, we are able to continue with our daily lives without disruption. This is not OCD. It does not cause us undue distress and we can function normally.

This is also not psychosis. We have all heard the tragic stories on the news of mothers taking the lives of their children. The women in these stories almost certainly suffer from psychosis or other serious mental health disorder and typically have a long history of problems. When they think of harming their children, they are typically under the delusion that doing so would be a good thing. Hearing these stories, unfortunately, fuels the fears of postpartum women. In contrast, those with OCD are horrified by the intrusive thoughts and may go to great lengths to protect their children; the thoughts are extremely anxiety provoking. I have never heard of a woman with postpartum OCD killing her child.

Risks for developing it and prevalence rates

For some women, their symptoms of OCD seem to come out of nowhere. Researchers have found that all women are at higher risk for OCD following the birth of a child. Typically, however, women have had a history of OCD or other psychiatric disorder (such as depression or anxiety) or had complications during pregnancy or birth (Zambaldia, Cantillinoa, Montenegroa, et al., 2009). One’s thinking style, such as perfectionism, can also predispose a person to develop it (Timpano, KR, Abramowitz, JS, Mahaffey, BL, Mitchell, M, & Schmidt, N, 2011). Zambaldia et al. found that 9% of the 400 women they test met the criteria for OCD, but others (including me) believe that number is much higher; one small study found that 29% of the women in their study, who were in their third trimester of pregnancy, met the criteria for OCD, and that number went up in the one month after giving birth (Chaudron & Nirodi, 2011).

Why mothers stay silent

Mothers who have intrusive thoughts often avoid telling anyone of their scary thoughts because they are afraid others may think they are crazy. Sadly, they may themselves question their sanity. Those who have thoughts of themselves harming their babies are even less likely to disclose this information because they fear that their babies will be taken from them and that they may be locked up. They often feel intense shame. They may desperately want to tell someone to relieve the burden of their secret, but unless they are adequately informed about postpartum OCD and unless they can find someone in whom they can trust about the nature of their problem, they will likely stay silent. This is why I am so adamant about educating people about the nature of intrusive thoughts and OCD; if the reality of intrusive thoughts was common knowledge, women would be able to reach out and learn how to find relief.

When to get help

Most new parents will have intrusive, scary thoughts at some point following the birth of a child. It’s when those thoughts increase a person’s anxiety, stop them from enjoying time with their baby, impact the choices they make, and make it difficult to enjoy life, that she would benefit from professional help. Depression often accompanies Postpartum OCD, so having a depressed mood nearly every day for most of the day is another symptom to play close attention to.

It goes without saying that anyone who wants to harm his or her baby, doesn’t think it’s a really bad idea to act on these thoughts, and/or has a plan or intention to hurt her baby, needs to seek help immediately.

A message to moms

If you are a mother who is experiencing intrusive, scary thoughts, you are not alone. You are not crazy. Just because you have horrible thoughts, it does not mean that you’re going to act on them; no matter how awful they are, your thoughts do not make you a bad person. Also, Postpartum OCD and psychosis are two different things; one does not turn into the other. I also want to repeat what I said earlier — I’ve never heard of a mom with postpartum OCD killing her child. The best news is, help is readily available.

You can seek out the help of a therapist who specializes in postpartum issues (see my previous post about how to find a therapist). If you’re lucky enough to live in the Portland, Oregon area, you can contact Baby Blues Connection (BBC) and talk with someone over the phone at no charge who has suffered through — and come out the other side — of postpartum OCD. They can also tell you if there are free support groups in your area. If you do not have an organization such as BBC near you, call Postpartum Support International (PSI). They get it. If you’re still unsure whether or not you can trust such an organization, you can always call and ask what they know about intrusive thoughts. Doing so may allay your fears.

If group or individual therapy is not an option for you, call PSI for support, learn diaphragmatic breathing and practice it daily, eat healthy food, exercise, DO NOT isolate, and get Karen Kleiman’s book (listed in bibliography). You don’t have to feel this way forever. Be good to yourself; both you and your baby deserve it.

What friends and family can do

If you are lucky enough that a mom confides in your about having intrusive thoughts, listen without judgement. Know that she is not exaggerating the depths of her distress and anxiety, or how real and vivid the thoughts can be. Don’t minimize her feelings or tell her that she’ll be fine. Let her know that she can get help. If she wants information, point her to Postpartum Support International or this blog post. Discourage her from searching the internet about her symptoms. Unfortunately, there is a lot of inaccurate  information that could exacerbate her fears. If she says things such as, it would be better if I weren’t around, or otherwise indicates that she would be better off dead, seek professional help immediately.

Keep in mind that no one decides they want to get Postpartum OCD. They’ve done nothing to deserve it and they have not brought in on themselves. It is important to avoid blame, because adding that onto the guilt and shame they already feel will only make things worse.

And please…spread the word…okay? You may just save a life by doing so.

Bibliography

Chaudron, LH, Nirodi, N. (2010). The obsessive-compulsive spectrum in the perinatal period: A prospective pilot study. Archives of Women’s Mental Health, 13, 403-10.

Kleiman, K, Wenzel, A. (2011). Dropping the Baby and Other Scary Thoughts. New York, NY: Taylor and Francis Group.

Timpano, KR, Abramowitz, JS, Mahaffey, BL, Mitchell, M, Schmidt, N. (2011). Efficacy of a prevention program for postpartum obsessive-compulsive symptoms. Journal of Psychitaric Research, 45, 1511-7.

Zambaldia, CF, Cantilinoa, A, Montenegroa, AC, Paesb, JA, de Albuquerqueb, TLC, Sougeya, EB. (2009). Postpartum obsessive-compulsive disorder. Prevalence and clinical characteristics. Comprehensive Psychiatry, 5, 503-9.

How to stop smoking

There are no magic wands when it comes to stopping smoking. What works for one person may not work for the next. And what didn’t work the first time around, may work the third or fourth. If this is your first attempt to stop, know that there are many people who are successful that first time. If you have tried before and want to try again, you are also not alone. Remember that each attempt brings you closer to your goal. Keep going and don’t let mistakes discourage you.

Below you’ll read about some of the factors that can affect a person’s chances of success, as well as approaches commonly used. The list is far from exhaustive.

Index of topics:

Motivation
Depression
Medication
Nicotine gum and patches
Cognitive-behavioral therapy (CBT)
Hypnosis
Exercise
My combination of approaches
My next post

Motivation

The biggest factor for successful smoking cessation is motivation. If you want to stop because someone else says you should, or if you want to but still have reservations, then you are much more likely to start smoking again. How would being smoke-free personally affect you in the short-term? Would you be able to breathe easier? Have more money? Not have to sit outside in the cold so you can smoke? Have more time? One way to determine your motivation level is to ask yourself: are you ready to throw out ALL cigarettes, lighters, and ashtrays? If so, you’re probably ready.

Depression

Fact is, smokers are more likely than non-smokers to be depressed. And depression and anxiety makes it more difficult to stop smoking. Interestingly, one study found that Caucasian and Black depressed individuals, but not Latinos, have a harder time stopping smoking when depressed. If you go to a therapist to help you stop smoking, he or she can help you decide whether or not other issues need to be addressed before starting a smoking cessation program. This will probably help your chances of successfully stopping.

Medication

Buproprion, otherwise known as Zyban and Wellbutrin, has been prescribed for depression for many years and has shown to be effective for some people to stop smoking. It works by reducing one’s cravings and withdrawal effects. In a well-cited, well-designed  study by Hurt, Sachs, Glover, et al. (1997), a large number of smokers were given various doses of a sustained-release form of Buproprion for 7 weeks. Those taking the highest doses (150 and 300 mg) had the best results. They had few side-effects and little weight gain. After the 7-week trial period, over 44% of those taking the 300 mg dose had stopped smoking. However, that number dropped to a disappointing 23% one year later. Perhaps more effective is a newer drug, Varenicline (aka Chantix). It works by reducing both cravings and the pleasurable effects of smoking. Many individuals have reported gastrointestinal issues (nausea, gas, and constipation being the most common) while taking Varenicline and in the USA it carries a “black box warning;” it may cause depression and increases the risk for suicide. Of course, as with any medication, it’s important to talk with your doctor about how to take it and the possible side-effects.

If people find that using a medication helps them stop smoking, then I’m all for it. Other than a risk for some side-effects, the biggest potential problem is that for many people who take this approach, it simply isn’t enough by itself; once they stop taking the drug, they have no behaviors that they’ve learned to help them sustain their new, smoke-free habit.

Nicotine gum and patches

Nicotine gum and patches have been a mainstay of smoking cessation protocols. Their use is recommended by the American Lung Association and many other medical professionals believe them to be essential. That’s why a recent study, published in the NY Times, was so surprising. Nearly 2000 people were studied over time and it was found that patches and gum were of no help in long-term success. Heavy smokers who used them, in fact, were twice as likely to relapse as heavy smokers who did not use them.

Cognitive-behavioral therapy (CBT)

Most smoking cessation programs incorporate both cognitive and behavioral techniques (heavy on the behavioral) into their treatment protocols and people find them helpful. Essentially, it gives a person a toolbox of coping mechanisms to rely on. Obvious recommendations, such as making sure you no longer have easy access to cigarettes, are included. But a better program will help you identify potential situations in which you would be likely to start smoking again, and formulate strategies for what do in such situations. You’ll learn relaxation techniques, how to beat the cravings, and develop a plan in case you make a mistake. CBT by itself is not necessarily more successful than other approaches, but when used in the combination with other methods, it can be very helpful.

Hypnosis

Hypnosis is a powerful way to stop smoking. A well-written article about the power of hypnosis can be found here. In a study by Carmody, Duncan, and Simon (2008), it was found that those who used hypnosis were much more likely to be smoke-free one year later when compared to a group who were given standard behavioral counseling alone. Other research has found it to be more successful than other approaches, with success rates ranging from 20-50% one year after treatment. A 2004 study by Elkins and Hasan found that over 80% of people stopped smoking after a 3-session hypnosis program, and 48% reported they remained abstinent after a year. However, some people may not want to admit to researchers or their therapists that they have started smoking again, so these numbers could be somewhat inflated. Physical measures, such as those that can detect carbon monoxide levels, are the best way to be sure that a person has stopped, but most clinicians do not have access to such devices. Still, from both anecdotal evidence and what I have read in the research literature, hypnosis appears to be the most effective way for people to stop smoking when they are motivated to stop.

If you go looking for online for hypnosis programs to help you stop smoking, you’ll find a lot of people making big promises: Satisfaction, guaranteed! 99% success rate! If you see claims like these, it is too good to be true. I recommend that you find someone who has his or her advanced degree and/or license in psychology, medicine, social work, or related field, in addition to being a hypnotherapist; there are many lay hypnotists out there who have no training in how to help people manage the psychological component of a smoking cessation program, and that’s a pretty major component to ignore. It’s best if the professional you choose has received his or her training from a reputable organization (such as the American Society of Clinical Hypnosis). While CDs and online programs may help some people, they just aren’t going to be as effective as seeing seeing someone who can tailor their program to your specific needs.

Exercise

Exercise is typically a part of smoking cessation programs and there is reason to believe that exercise can help people abstain from smoking. In one promising study, it was found that sedentary female smokers who exercised vigorously three times a week were more likely to be non-smokers one year later.  Not all studies have shown such clear cut, positive outcomes, but what does seem to be clear is that exercise helps control cravings and withdrawal symptoms and also helps people maintain their weight after they’ve stopped smoking. Exercise also improves a person’s psychological and general health. Those are a lot of good reasons to exercise, so I recommend that my clients start a regular exercise program. Still, starting and stopping two new behaviors at the same time can be challenging, so if the exercise doesn’t happen immediately, that’s okay too.

My combination of approaches

Although the research has not identified one approach as being the gold standard of smoking cessation programs, by using a combination of approaches, many people succeed in becoming non-smokers.  That’s why I use primarily hypnosis and CBT, as well as the recommendation to exercise. If a client is under the care of a medical doctor, I am open to that person using medications if he or she finds them helpful. I interview clients during their first session so that I can look for signs of depression or other issues that may need to be addressed before a successful smoking cessation program is started. Although there are one-session smoking cessation protocols, by talking with clinicians and reading the research, I have learned that a minimum of four sessions are needed for the best results. I understand when people are most tempted to relapse and take that into account as well.

With the right tools and support, you can stop smoking and breathe easier once again. Find your motivation, find a good therapist, and keep at it! I wish you the best in your efforts.

My next post

For my next post I’ll write about Postpartum OCD, something that few people know much about but is more common than most people realize.

Bibliography

Elkins, G, and Hasan, R (2004). Clinical hypnosis for smoking cessation: Preliminary results of a three-session intervention. International Journal of Clinical and Experimental Hypnosis, 52: 73-81.

Hurt, R, Sachs, D, Glover, E, Offord, K, Johnston, J, Dale, L, Khayrallah, M, et al. (1997). A comparison of sustained-release Buproprion and placebo for smoking cessation. Massachusettes Medical Society

Marcus, B, Albrecht, A, King, T, Parisi, A, Pinto, B, Roberts, M, Niaura, R, et al. (1999). The efficacy of exercise as an aid for smoking cessation in women. Archives of Internal Medicine, 159: 1229-34.

Webb, M, Rodriquez de Ybarra, D, Baker, E, Reis, I, and Carey, M (2010). Cognitive-behavioral therapy to promote smoking cessation among African-American smokers: A randomized clinical trial. Journal of Consulting and Clinical Psychology; 1, 24-33

Yessenia, C, Costello, T, Correa-Fernandez, V, Heppner, W, Reitzel, L, Mazas, C, et al. (2011) Differential effects of depression on smoking cessation in a diverse sample of smokers in treatment. American Journal of Preventive Medicine; 41, 84-7.

Zelman, D, Brandon, T, Jorenby, D, and Baker, T. (1992). Measures of affect and nicotine dependence predict differential response to smoking cessation treatments. Journal of Consulting and Clinical Psychology; 60, 943-52.

Panic and Exposure Therapy

First, the good news: Panic Disorder is very treatable. And the bad news isn’t so bad, really. It’s just that you have to be committed to the process of getting better and you will need to work hard. In this post I’ll explain what Panic Disorder is, describe an effective treatment approach, and explain why commonly used methods for relieving anxiety may actually exacerbate it.

What is Panic Disorder?
Agorophobia and other risks of Panic Disorder
How does one develop Panic Disorder?
The tenacity of the four Fs
Treatment overview
Don’t make it worse
My next post

What is Panic Disorder?

Those with Panic Disorder (PD) have a number of intense physical symptoms that typically last for 10 minutes or less, but attacks can continue for much longer if one rolls into another. They are extremely frightening and uncomfortable, especially if the person believes there may be something physically wrong with him or her. Physical symptoms may include rapid heart beat, shortness of breath, tingling of the extremities, dizziness, feeling of choking, trembling or shaking, stomach upset, chest pain, chills or hot flashes and the person may feel oddly unreal or detached from themselves. Not fun. People who have these attacks may think they are having a heart attack or stroke, that they are going crazy or may lose control, or feel very embarrassed and self-conscious. Attacks may be brought on by seeing something that frightens you, such as snakes, or they can be triggered by certain situations, such as being in a crowded place. Most attacks, however, seem to come out of the blue (although recent research has shown that physiological changes actually precede “sudden” attacks), which is a hallmark of Panic Disorder. Recent research has shown that stressful life events may exacerbate the severity of a person’s panic attacks. This may explain why new moms often experience Panic Disorder for the first time.

The person with panic often feels a desperate need to escape and will do anything to avoid experiencing another attack. Left untreated, the anxiety typically gets worse.

Many people with Panic Disorder end up going to the Emergency Room or their doctor’s office at some point because they think there must be something physically wrong with them. If you’re like many people, you may not believe the doctor when she says you had a panic attack. You may also feel embarrassed because you were so sure that you were having a heart attack. This is a normal response but it’s important not to let your feelings of embarrassment stop you from getting treated. In fact, it’s a good thing that you went to the doctor because we know that you’re in good physical health. We can now move on to treating the anxiety.

Agorophobia and other risks of Panic Disorder

Agoraphobia sometimes develops as a side-effect of Panic Disorder and is, generally, a fear of public or open spaces. It develops because the person has had panic attacks that have scared the person so much that he avoids the places and activities he has associated with the attacks; he has been conditioned to believe he will panic in such places and will be unable to escape. At this point his symptoms have a big impact on his life and may seriously affect his relationships, employment, activity level, sense of freedom, and likely even his sense of self. According to the American Psychological Assocation (APA), those with Panic Disorder are also at risk for developing:

• debilitating phobias
• depression and suicidality
• alcohol and drug abuse
• feeling less emotionally and physically healthy
• fear of leaving home

Again, it doesn’t have to rule your life and the treatment is effective for the vast majority of people who seek it.

How does one develop Panic Disorder?

It is difficult to pinpoint the exact cause of PD. Most of those who have it have had some problems with anxiety for most of their lives. The latest data point to a genetic component. Drug use may lead to an initial attack and so can mounting stress and responsibilities; panic attacks often first surface in times of transition. Smoking cigarettes may exacerbate the problem and those who smoke have have poorer treatment outcomes. Sometimes the death of someone close to us can be a trigger. At other times, no likely cause can be identified. They typically begin before the age of 30.

The tenacity of the four Fs

Panic is adaptive in some situations. If we are hiking in the northern hills, round a corner and suddenly find ourselves face-to-face with a bear, then it’s a good thing our bodies act the way they do. This is when our sympathetic nervous system kicks in, and it’s a good thing. In those cases, we are likely to do one of four Fs, all of which may save us: 1. Freeze. Some animals sense movement, so if we don’t move, they may not be able to see us or think we’re a threat and leave us alone. 2. Faint. If the animal thinks we’re dead, then they’re likely to move on or just play with us a bit. 3. Flight. If you run, they may not give chase and perhaps you can escape. 4. Fight. As a last resort, fighting may work against smaller, weaker predators, especially if you have some sort of weapon.

What’s interesting is that the physical symptoms during a panic attack are all things that can help us in that rare, dangerous situation described above. When our heart rate increases, blood is pumped toward our major muscle groups, such as our quadriceps, so that we can run. Sweating not only cools the body, but it makes us more slippery so that a predator has a harder time grabbing us. Tingling or numbness in the fingers and toes helps to draw blood toward the major muscle groups but also makes it less likely that we will not bleed to death if our hands gets injured in a fight. Do you tend to get dizzy? That is often a result of hyperventilation; fainting would be F #2, playing dead (but it is very rare that people actually faint during panic attacks).

While panic used to serve the purpose of ensuring our survival in times of danger, our environment has changed. Apart from the occasional mugger, rarely do we encounter situations in which we need the four Fs. Rather, we may have arguments with loved ones or co-workers, need to make a speech, or have tight deadlines we need to meet. Still, on occasion, our bodies continue to rely on their old tricks. When that happens, we can re-train our bodies and brains to respond more appropriately.

Treatment overview

Organizations such as the National Institute of Mental Health (NIMH) and the American Psychological Association (APA), and the American Psychiatric Association recommend CBT as the treatment of choice for PD. Although medications are also endorsed, below I explain why I think they are typically unnecessary in treating PD and can actually complicate it. If you have true PD, then the treatment is fairly straightforward. I follow the recommendations of Barlow and Craske,who have created a treatment model that combines educational, relaxation, cognitive, and behavioral components. Technically, it is a branch of CBT called “exposure therapy.” In my opinion, it is far and away the best approach and takes, on average, 10-16 sessions, depending on the individual’s specific needs.

It is certainly easier to take a pill than it is to go to a therapist and follow through on treatment recommendations, but psychotherapy is a better way to go. For most people with Panic Disorder, medication is unnecessary and only complicate treatment (but treatment is still fairly straight-forward). One problem with taking medications alone is that you will likely have to continue taking them indefinitely if you do not want to re-experience panic attacks. Also, anti-anxiety medications are potentially addicting, and anti-depressants are both less effective for panic and can lead to rebound effects when stopped. However, in some cases, especially if a person is also very depressed or suicidal, medications are an important part of treatment for PD. Never stop medications on your own; there can be serious effects from doing so. Please follow the recommendations of your doctor.

Don’t make it worse

One of the biggest components of treatment include helping you to recognize when you’re using avoidance. For those with anxiety, avoidance is a key component in maintaining and exacerbating your symptoms. When you avoid something that you associate with symptoms of panic, you actually increase both your anxiety and the likelihood that you will panic. For example, if you avoid driving over bridges because you think you may panic while driving over one (and perhaps you have in the past), then you will teach your body and brain that it is, in fact, too dangerous to do so. Your avoidance and fear of bridges will likely increase and you could develop a severe phobia of bridges. Your risk of having a panic attack on a bridge also increases.

Avoidance also applies to panic attacks themselves. As scary and uncomfortable as a panic attack is, it is not dangerous. If you find yourself panicking, remind yourself that while it is very uncomfortable, it will not kill you. You do not need to try to escape it. Each time you try to escape it, you are turning up the volume on future attacks and you may lengthen the duration of the attack. Again, by using avoidance strategies, you are teaching your body that panic attacks are too dangerous and must be avoided at all costs. When your body learns this, it reacts by going into panic mode more easily. You brain learns that it needs to be on high alert and may interpret harmless bodily sensations (such as an increased heart rate during exercise) as dangerous — once again, sending your body into panic mode.

A good therapist can help you identify your avoidance behaviors and give you tools and information to help you manage any attacks you may have. You will be given activities to practice at home, which are a vital part of your healing process.

Often people with PD spend a lot of time on the internet, trying to find a medical reason for their symptoms. This will only make things worse. It’s likely that you’re looking to confirm that you are seriously ill, and you won’t stop until you find something truly frightening. Chances are, you’re young, in good health, and have been told so by your doctor. There is no good reason to doubt her. There is, however, good information on the internet about Panic Disorder. Still, be a skeptical consumer; just because it’s on the internet, does not make it true.

I love working with clients who have Panic Disorder. Those I have seen who have been motivated to follow through with treatment see dramatic results. Best of all, they rediscover how to enjoy life. What could be better than that?

My next post

For my next post, I will talk about how you can stop smoking. I’ll include a description of different treatment options and your chances for success.

Bibliography:

Meuret, A; Rosenfield, D; Wilhelm, F; Zhou, E; Conrad, A; Ritz, T; Walton, T (2011). Do unexpected panic attacks occur spontaneously? Biological Psychiatry, 20, 985-91.

Moitra, E; Ingrid, D; Courtney, B; Bjornsson, A; Sibrava, N; Weisberg, R; Keller, M. (2011). Impact of stressful life events of the course of panic disorder. Journal of Affective Disorder, 134, 373-6.

Rosqvist, J (2005). Exposure Treatments for Anxiety Disorders: A Practitioner’s Guide to Concepts, Methods, and Evidence-Based Practice. New York: Taylor and Francis Group.

How to Find a Therapist (Part II): Where do I Begin?

Let’s say you have a list of therapist names. You know you need to call, but you keep putting it off. What are you supposed to say? What questions should you ask? And what is therapy like? If you have never been in therapy, or even if you have, therapy can seem like a foreign land where you have not yet learned the language or customs.

Index of topics:

The first interview
Confidentiality
Limits to confidentiality
How much time do I get with my therapist?
What is it like to be in therapy?
What if things are not going well?
Is there anything I should avoid saying?
A unique relationship
How do I know when we are done?
Next post

The first interview

The good news is that there’s nothing you have to ask. In fact, my clients rarely interview me. Still, I always hope that they will. If you can find out whether the therapist will be a good match for your needs during that first phone call, you may save yourself time and money.

As I mentioned in my previous post, the basics include telling your therapist about your primary symptoms, your reasons for pursuing therapy now, and also whether or not there is some urgency to your situation. The therapist will almost certainly ask you follow-up questions.

Before you pick up the phone, think about what may be important for you. Is it confidentiality? Credentials? Getting an idea of how long therapy will last? These are all valid questions. If you are considering paying “out of pocket” (not using insurance), consider what you are willing and able to pay. Think about how much your mental health is worth to you and how much you can afford over the course of several weeks or months; I always tell my clients that I don’t want them to pay me so much that it will mean they will have to cut their treatment short, but not all therapists have a sliding fee scale.

Other questions to consider include:

• What insurance do you take, if any?
• Do you have a sliding fee scale or any low-cost options?
• What kind of training do you have?
• What is your experience in helping people with my problem?
• How long can I expect treatment to last?
• How do you measure progress?
• How will you know when I’m done with treatment?
• How do feel about working with people who are gay/Christian/black/physically disabled/etc? (You want to be sure your therapist will make you feel welcomed, accepted, and supported, especially if you are feeling rejected from your community.)

This list is not exhaustive, by any means. Again, think about what is important to you.

Confidentiality

The conversations that you have in the privacy of your therapist’s office are confidential. That means that he cannot talk about what you have said, or even that you are his client, to anyone. However, there are exceptions to this rule, which I’ll talk about in the next section. In most cases, you should have the opportunity to read and sign an Informed Consent form prior to your first session, which explains the therapist’s general policies, including limits to confidentiality.

There are two primary advantages to confidentiality. First, it allows you some privacy. Even more important, however, is that it gives you the freedom to open up completely to your therapist, sharing the most intimate, personal details of your life with him. This is rarely done in the first session and is most important if you are engaged in exploratory work, as opposed to something more task specific, such as stopping smoking. It is done over time, as your relationship with your therapist grows and you’ve come to feel safe and supported by him. Only by opening up and sharing things with him that you might not share with anyone else, is he able to really help you. For example, perhaps you smoke marijuana regularly. If you kept that from your therapist, not only might he misattribute your reported memory lapses to some other cause, but it would also mean that you couldn’t be completely forthcoming about the tension between you and your significant other, who, perhaps, disapproves of your habit. This would make it very difficult for your therapist to help you with the relationship problems that you report to him.

A good therapist cares about keeping your relationship confidential, so she will probably not strike up a conversation with you if you happen to see her in the mall or at a restaurant. In fact, your therapist may pretend she doesn’t even know you. Although it can be uncomfortable for you both, who likely have a close relationship, it is because your therapist is respecting your privacy and the importance of it that she behaves this way. Although it is your right to tell anyone you want that she is your therapist, she is ethically bound not to acknowledge the true nature of your relationship. You may, during therapy, discuss how you would like to handle the situation if, in fact, you happen to cross paths in public.

Limits to Confidentiality

There are times when your therapist may talk about your case with others. Most commonly, therapists consult with other psychologists or meet with a supervisor. They talk with other professionals in order to give you the best care. Every professional involved in your case is required to maintain confidentiality and they avoid giving identifying information about you when possible. Because different therapists have different specialties and experiences, everyone, and especially you as the client, benefits from this practice.

If a therapist has reason to believe that you are in imminent danger of hurting yourself or someone else, he will need to get help for you. In most states there are also laws about reporting child abuse, elder abuse, and animal abuse. Also, if you pose a threat to someone else, in some states he may have to contact that person to whom you pose a threat. There are variations of this law in different states, so I cannot address law where you live. The best way to be informed is to read your therapist’s Informed Consent Form (he should provide you with one before the fist visit), ask for clarification if needed, and/or contact your state’s board of psychologist examiners; most, if not all, have their statutes and rules posted online, as well as information about how to report violations.

If you are using insurance, you are essentially giving your therapist permission to tell the insurance company about your diagnosis, progress, treatment plan, and so on. Also, if you are involved in the legal system, some lawyers may think your therapist could have juicy information about you that may help their case. Psychologists are obligated, however, to protect your privacy to the greatest extent that they legally can and may or may not have to comply with a subpoena. This is where it gets complicated, because of differences between situations, therapists, clients, attorneys, judges, state laws, professional ethics codes, and so on. In truth, it is difficult to predict what will happen because the details of each case differ.

How much time do I get with my therapist?

Sessions will run 45 or 50 minutes, depending on your therapist’s preference. Some therapists, like me, reserve 80-90 minutes for the first session because she wants to have enough time to ask about the problem you are reporting and get your background information. “Intake” sessions, as they are called, are charged at a higher rate because of the extra time she spends with you.

Even though you don’t get a full 60 minutes with your therapist, you are likely getting more than an hour of her time. There are notes to write, other professionals to consult, phone calls with you, treatment plans to write, and for the majority of professionals, insurance companies to correspond with. Most therapists include, in their consent forms, a provision that says you may be billed for extra time spent on your case. Most will charge for any phone calls or consultations that exceed 10 minutes. Different professionals have different policies, so be clear about your therapist’s policy.

What is it like to be therapy?

If your therapist didn’t have you complete your paperwork ahead of time, this is how you’ll probably spend the first part of your first session. Paperwork may include an Informed Consent form, a standard explanation of HIPAA and how it applies to therapy, perhaps a release of information form (so that your therapist can coordinate your care with other providers, if applicable), and sometimes psychological measures. Not only do such measures give your therapist a quick idea of how you are doing, but they can also give her a baseline against which she can later measure your progress.

While a therapist can give you a general idea of how long it typically takes to treat someone with your problem, there are always individual differences that may affect this timetable. Therapists typically take up to four sessions to complete their assessment of your particular case. Think of this time as a “trying on period” for the both of you. It takes this long to get your full history, learn about your symptoms and how they may change over time, learn about your strengths and weaknesses, and develop a good understanding of your problem. Only then can she realistically formulate a treatment plan. Although you may stop treatment at any time, the first four meetings should give you ample time to decide whether or not the therapist is right for you.

Some of my clients, especially during a first visit, say that they feel nervous, or that they’ve “never done this before.” It’s okay to feel nervous, but there’s really nothing you need to know about therapy before beginning; there is no “right way.” If you’re stumped for something to say, tell your therapist that. Each person has his or her own experience in therapy. It depends on you, it depends on the problem, and it depends on the therapist’s personality and style. The therapists’ theoretical orientation will also have a major impact on your experience. If your therapist has a psychodynamic approach, she will likely allow you to start talking first and will give you a lot of “space” to think, feel, and speak. A CBT therapist is more likely to be talkative and instructive. However, I am generalizing; you can have a very instructive, directive psychodynamic therapist and some CBT therapists are more talkative than others.  Although therapists vary greatly on how warm they are, you should feel as though your therapist wants to help you.

Some people feel an instant connection with their therapist, but that’s not the norm. It usually takes time to get to know someone and establish a relationship that makes it feel safe to open up and share personal information.

What if things are not going well?

Even if you interviewed a few therapists and thought you found the right one for you, you may find after a few sessions that a therapist is not the right fit for you. If you have concerns, a good therapist will want you to raise them. If the answers you get do not satisfy you, it is perfectly acceptable to move on. After the evaluation period (generally the first 3-4 sessions), your therapist may also decide that he is not the best therapist for you. For example, if he determines that you have Obsessive-Compulsive Disorder but has no experience treating it, he will likely refer you to someone else.

It’s nice to like your therapist, but it’s not enough. Therapists can be really warm, caring, supportive, and you can like them a lot…but can they help you? If you don’t think that you are making progress toward your goals, tell your therapist your concerns. This can feel scary to some clients, but I assure you, a good therapist will be happy that you said something. This gives him the opportunity to ask about your concerns, explain his treatment approach, and maybe make some changes; in fact, such conversations can often be very helpful to the therapeutic process. After talking about your concerns, you and your therapist may agree that perhaps you would be better served by going to someone else and he can give you referrals to other professionals. If you find the therapist is defensive or does not otherwise react well, then it’s a probably time to find a new therapist.

Is there anything I should avoid saying?

Not really. Talking about the day-to-day details of your life during every session will not be useful material for therapy. However, in the beginning of therapy, this is where you may dwell. Once you feel comfortable, you can move on to the bigger issues, patterns, and themes in your life. That makes for good therapy.

A unique relationship

The therapist-client relationship is a unique one. You, as the client, reveal intimate details about your life, while you will probably learn little about your therapist. This makes sense, of course, because the work is about you. Once you end therapy, you may or may not need to talk with him or her again. Don’t try to friend your therapist on Facebook or provide reviews of their work on a public site; it would be a violation of your privacy and puts the therapist in the awkward position of telling you they cannot publish all the nice (or not-so-nice) things you said about her.

Your therapist in not your friend. This is not to say that your therapist does not care for you; on the contrary, it’s likely that she cares about you very much. So much, in fact, that she does everything she needs to maintain professional boundaries. Dual relationships (such as, if your therapist is also your next door neighbor or your hairdresser), interfere with the therapeutic process. Your therapist loses perspective and can no longer be helpful if she becomes too emotionally involved with you. A good therapist is able to strike a balance between caring for you and not becoming emotionally involved with you.

Sexual contact is NEVER permissable as part of therapy (ever watch the HBO show, “In Treatment?” That therapist had issues). Even if you end therapy, a personal relationship with him or her is potentially damaging to the work you have done and is frowned upon by professional organizations, such as the American Psychological Association. If you believe that your therapist has behaved inappropriately toward you, contact your state’s board of psychological examiners.

How do I know when we are done?

It is good to talk with your therapist regularly about your progress. This way, it’s not a surprise to either of you when he tells you it’s time to stop, or when you say you no longer think you need to come. If there are other issues that you would like to work on after resolving your current problem, be sure to let your therapist know.

Oftentimes your therapist will talk about relapse prevention with you and may see you a month or several months later to help make sure you are maintaining the gains made in therapy. This practice varies widely between therapists, however.

It can be difficult to stop seeing your therapist after you’ve developed a relationship with him. Some clients feel as though they owe their therapists a debt of gratitude and may bring him a gift. Although we as therapists need to be sensitive to why this is appropriate in many cultures, it is generally frowned upon in the psychology profession. And really, seeing a client progress to the point where he no longer needs treatment is a wonderful gift to a therapist.

Next post

My next post will be about Panic Disorder. Learn what it really is and how it can be successfully treated. Is there a topic you’re interested in reading about? Let me know!

How to Find a Therapist (Part I) — Before You Begin

Sometimes the biggest hurdle to starting therapy is figuring out how to begin. And if you’re feeling particularly bad, the thought of finding a therapist can seem overwhelming.

If you want to keep it simple, go to the section, “Where to Look.” If you want to be an educated consumer, read on.

Index of topics:

Why do you want to start therapy?
Understand what is involved
Therapist qualifications
Licensed or not?
Therapist orientation
Where to look
Specialties and skills
Next steps

Why do you want to start therapy?

It is important to be clear about your reasons for starting therapy. Not only will the therapist ask you this question, it will help you select a therapist who has the skills to help you. Here are some typical reasons for starting therapy; however, you may have a combination of these:

• you are feeling distressed and your distress is interfering with your daily life;
• you are having relationship problems;
• you have been engaging in some kind of self-destructive or harmful behavior;
• you want to start or stop a new habit, or
• you want to understand yourself and the reasons you behave and the way you do.
• you want to figure out your life direction

Most therapists allot a certain amount of time (10-20 minutes, typically, and at no charge) to talk to potential clients over the phone. You’ll want to tell him or her the specifics about why you’re seeking therapy. For example, it’s okay to tell the therapist that you think you may be depressed, but even better to also say why: I’m having a hard time getting motivated to get out of bed in the morning and feel totally overwhelmed by simple tasks. It’s also a good idea to include your reason for calling now: it got to the point where my boyfriend said he was going to break up with me if I didn’t pull things together. And if it’s urgent, please let him or her know: I’ve been having thoughts of killing myself. There’s no need to go into all of the details of your situation. The therapist will ask you what he or she needs to know and it’s a good idea to leave enough time to ask the therapist questions as well (more on this in the next blog post).

Understand what is involved in therapy

Before you make the first call, ask yourself how committed you are to the therapeutic process. Is this a change you want to make, or are you doing it because someone else thinks you should? Good therapy is not something that is done to you; rather, in order to make real, lasting changes, you will need to take responsibility for your mental health and you need to be motivated. It can be hard work. It may bring up painful aspects of your past or present and for some, things may get worse before they improve. Although there are some circumstances when a person’s environment is the major contributor to the problem (such as in cases of child abuse or discrimination), it is important that you be willing to look at some not-so-pretty aspects of yourself and how you are contributing to the problem. By doing so, your chances of improving your life will be better. As a practical consideration, you will be investing a significant amount of time and money into this process, so make sure you’re ready to do the work.

Therapist Qualifications

There are many types of degrees that a therapist may hold. Here are a few of the ones I often see:

LPCs (Licensed Professional Counselor), LCSWs (Licensed Clinical Social Worker) and LMFTs (Licensed Marriage and Family Therapist) are common designations. If there is no “L”, it probably means they’re not licensed. These therapists have completed a Master’s degree, have supervised training, and have passed licensing exams. They typically focus on problems with the family and other mental health problems. Professionals with these degrees typically charge less for their services and, in my opinion, are often very good at what they do.

Most therapists with doctorates are called Psychologists and have either a PsyD or a PhD. They typically have at least two more years of course work than those with Master’s degrees as well as more hours of supervised, clinical training. Many psychologists conduct psychological testing but may not prescribe medication in most states. (If you are looking for a prescriber, you will likely need someone with a medical degree, such as a psychiatrist or a psychiatric nurse practitioner.) Psychologists with a PsyD have been trained in “applied work;” they have been trained, first and foremost, as therapists. In PhD programs, student are also required to research and write a dissertation which needs to be a unique contribution to the field of psychology. Although many PhD programs train their students to be practicing therapists (such as my program), others emphasize research over practice.

A psychologist resident (as in my case) has graduated with a doctorate. She is working toward licensure by meeting weekly with a supervisor to talk about her clients’ cases, discuss ethics and law, and sometimes learn new skills. She must also take licensing exams. Although psychologist residents (called post-docs in some states) are not yet licensed, the state board of psychologist examiners has several requirements: they must have their degree from an accredited institution, have a contract with their supervisor, follow the ethical standards that all licensed psychologists must follow, and much more. As a bonus to you, they typically charge lower fees than those who are licensed and often have sliding fee scales.  Also, you have the advantage of having two professionals who are looking out for you and making sure you are getting a high level of care.

Don’t discount junior therapists! They often are very motivated and enthusiastic about helping their clients and they have the training behind them to be helpful. If they have the qualifications you’re looking for, they are worthy of an interview, at least. You may find that they are a good match for you and your needs.

See Psychology Today’s description of credentials. The list is lengthy: http://therapists.psychologytoday.com/rms/content/therapy_credentials.html

Licensed or not?

A license is not a guarantee of competence, but it does offer some reassurance that the therapist has been appropriately educated and is bound by the state to practice ethically.

Therapist Orientation

A therapist’s theoretical orientation dictates how he or she will go about helping you reach your goals. If you see the phrase, “evidence based practice,” that’s a good sign.; it means that the therapist uses techniques that research has shown to be effective. It is a standard that all therapists should use. I recommend that you stay away from unproven, pseudo-scientific approaches, such as past-life regression, rebirthing, etc. I will write in more detail about different theoretical perspectives in future posts.

Some of the most common orientations include psychodynamic/psychoanalytic; cognitive-behavioral (CBT); family systems; and eclectic. The kind of therapy that a therapist does can make a big difference in your experience.  It’s also important to know that while certain approaches have been endorsed by various psychological organizations as being most helpful for certain conditions, overall, the research says that one orientation is not more effective than another. Rather, what is most important is that you and your therapist have a strong working relationship. It’s also good to know that there is wide variability within each style, with some staying close to the original theories and techniques while many others incorporate bits of other orientations to supplement the therapy as they see fit.

Psychodynamic/psychoanalytic: If you want to understand the root cause of your problem, believe that examining your past can help you understand your problems, and value self-exploration, then this approach may work well for you. The dynamics of the relationship between the therapist and the client is an important focus of the work. You can expect the process be on the longer end of the time spectrum. Object-relations is a common variation of this approach.

Cognitive-Behavioral Therapy (CBT): CBT is focused on the “here and now.” While most CBT therapists will ask you about your past, the focus of the therapy is on helping you fix the problem rather than on understanding how it started. The therapist will help you examine your behavior and thinking patterns and teach you healthy, adaptive skills. Homework is often given between sessions. Insurance companies often like CBT because it is shorter term and research has shown that it is often effective. Mindfulness and Exposure Therapy are common variations of CBT.

Family Systems: This approach can be useful for individuals, but typically it is more productive to have more than one family member in session together. The therapist looks at systemic issues that maintain the problem and emphasizes how each person and his or her role in the family impacts everyone else.

Eclectic or Integrated: This designation essentially means that the therapist does not subscribe to a particular theory, but uses a combination of theories and techniques. Some therapists snub their noses at those who practice this way and truthfully, if the therapist is not very experienced, eclectic may be another name for confused. Still, there are plenty of good therapists who call themselves Eclectic. Be sure to interview all therapists before hand and don’t be afraid to ask how he or she would approach your case, and how soon would he or she expect you to improve? I’ll talk more about interviewing therapists in the next post.

Specialties and skills

In addition to a therapist’s degree(s) and theoretical orientation, referral services often include a therapist’s special skills and areas of focus. Skills may include biofeedback, EMDR (more on what this is in another post), exposure therapy for anxiety, hypnosis, and more. Areas of focus could include couple therapy, postpartum issues, sex therapy, pain management, addictions, or grief and loss. Although that can seem like a lot to sift through, chances are good that there are therapists who know how to help you with the problems you are facing.

Where to look

There are many ways to find a therapist. If you’ll be using insurance, I recommend checking with them first and finding out how many sessions they allow, how much your deductible and co-pays are, and whether or not there are other restrictions. If you choose not to use insurance, many good therapists offer reduced fees for those on a tight budget. If a therapist’s fees would prohibit you from getting help, ask them if they have a sliding fee scale.

If you use insurance, keep in mind that a mental health diagnosis may, sadly, be a stigma in the future and will be in your medical records. For that reason, some clients may prefer to pay “out of pocket.”

Your insurance company

If you want to use someone who is an “in-network provider,” your insurance provider can give you a list. You will likely pay more for those who are out-of-network, but if you can afford it, this will give you more freedom to choose someone you prefer.

Recommendations from Family or Friends

Some people prefer to get personal recommendations from friends and getting referral from a casual acquaintance is fine. However, it’s not a good idea when the person is someone close to you. While it can seem like a good idea to get a recommendation from someone who knows what it’s like to be in therapy with a particular professional, a good therapist will caution you against this and my even refuse to see you; when someone close to you shares your therapist, you may find that it can get complicated. Ultimately, you want to know that your therapist is going to be able to support you 100% and you don’t want to wonder where his or her allegiance lies. You also don’t want to feel as if you need to censor what you say or wonder whether or not your sister said anything about your recent argument in her session.

Professional organizations

The psychological association in your state has a referral service. In Oregon, for example, the Oregon Psychological Association has an online referral tool.  These days, it is fairly easy to find an organization that has information and support for those suffering from a particular problem. Many have referral services or directories. For example, I am currently a member of several, so you can find me through the Anxiety Disorders Association of America, the Oregon Society of Clinical Hypnosis, Postpartum Support International, and Baby Blues Connection.

Psychology Today

Psychology Today (PT), the popular magazine, has a big online presence. Of course, only those therapists who have signed up to be part of their directory will be listed.

Thumbtack

Thumbtack is a new service directory that is just getting off the ground (www.thumbtack.com). Like PT, only those who have signed up with them will be listed.

Colleges and Universities

Any institution that has a counseling center is likely to be able to give you a referral to a local therapist.

Search Engines

There are many tech-savvy therapists nowadays (or therapists who hire tech-savvy people), so they often have their own websites. Therapists’ websites often give you more information about them and the work they do. However, their sites are not always optimized to show up when you search for “Psychologist” in, let’s say, “San Jose California.” But if you find someone through another directory, oftentimes their website is listed. Be as specific as you can with your search, including your city and state, the problem area and/or skill you’re look for (depression, anxiety, biofeedback, etc.), and then something such as “therapist” or “psychologist.”

Next Steps

I recommend finding five therapists to call and interview, if you’re lucky enough to have that many to choose from. Sometimes a therapist can’t see you for three months and you can’t wait that long. Or, you find that the therapist you thought looked perfect on paper seemed like he misrepresented himself. You may also find that the last person on your list was the one you felt most comfortable with. So start with a pool of candidates and go from there.

What do you say when you call? What kinds of questions should you ask? What are you supposed to do in therapy? How confidential is it really? What is therapy like? Stay tuned for my next post to get the answers to those questions. In the meantime, be well and take care of yourself.

Welcome to your brain.

Welcome to your brain. In future posts, your brain will enjoy a variety of topics. Some such topics will include: how to find a therapist who is right for you; why therapy is not all the same; Panic Disorder; Postpartum OCD; why self-compassion is trumping self-esteem; sexual performance; how to stop smoking; how hypnosis can benefit the brain; is ADHD real? And that’s just the beginning. I take requests, too. This blog is not intended to be a replacement for therapy but rather is intended to educate. Although I will include recent research findings into my posts whenever possible, my posts will also be informed by my personal experiences and opinions. I envision posting articles by other mental health professionals as well and invite submissions, comments*, and questions.

*If you are a current or former client, please know that I am ethically bound to maintain confidentiality and will not publish comments (good or bad) about your experience working with me.