Watch this video with Dr. Dawn-Elise Snipes to learn a bit more about depression and antidepressants.
Note: If you are feeling suicidal or your depression is severe, contact a health professional immediately or dial 911 to be taken to your nearest emergency room. Online videos are not a substitute for the assessment and advice of a licensed healthcare professional.
Major Depression and Antidepressants
November 7, 2011 by
Responding to the Needs of Returning Veterans
July 6, 2011 by
Appropriate responses to the needs of returning veterans will include:
• A strength- and recovery-based focus
• An empowering, skill-training approach
• Careful, individualized, respectful, veteran-specific assessment and treatment planning
• A primary emphasis on stabilization and development of internal and external resources
• Education for veterans and families on the physical, cognitive and emotional aspects of trauma and substance use disorders
• Assertive linkage to ongoing support within the community—and in the larger military and veteran community nationwide
Effective responses to the needs of veterans with post-employment stress effects include a consistent approach that integrates trauma-informed addictions and mental health care, but what does that mean? It means that when treating a veteran for mental and/or substance use issues the clinician must realize that the traumas experienced have changed how the person feels, reacts and perceives the world. These changes are normal reactions to abnormal events. Unfortunately, they often persist even when the danger is past. This is the mind’s way of making sure the body survives. In order to help consumers to regain a sense of balance, we must create an environment of safety, trustworthiness, choice, collaboration and empowerment.
Safety means ensuring physical and emotional safety not only in the treatment session, but also in veterans’ daily lives. Even Abraham Maslow believed that safety helped form the foundation of mental health and wellness. When people do not feel safe, they are on guard, and they cannot rest well which negatively impacts their health, mood and relationships which could be supportive. So the next question I am often asked, is “What do they need protection from?” They need places where they are not subject to judgement or evaluation, and are not concerned they will have to defend their actions or the actions of the military in general. If they have been deployed for a while, they need a community that can help them feel less like a stranger in a strange world. They need places where people understand what they are going through, who have survived the nightmares, the insomnia and the feeling of utter isolation, not knowing who they can trust. They need to learn the skills to deal with the flashbacks and the nightmares, and to relaxs at the end of the day.
Trustworthiness is developed in the process of creating safety by maintaining clear, appropriate, consistent boundaries and objectives. Many people—veterans included—will not tell you everything until they believe you are trustworthy. Those things that haunt them at 2am are not things they are going to tell just anybody. Throughout the process that led to the PTSD–whether it be one single incident or years of traumas—the person regularly was stripped of their control, second guessed for every move and, often questioned on their decisions. Trauma informed treatment not only relies on consumers learning to trust their therapists, but also on them learning to trust themselves. Failure to keep promises reinforces the notion that the world is an unpredictable, terrifying place. Failure to help consumers see the logic in what they did, or are doing, reinforces the notion that their behavior is unpredictable and they are out of control. Remember to ask yourself what the benefit is to any behavor. Our brains are programmed to survive. How is the behavior helping the person survive. Substance abuse numbs pain and helps people survive until they develop alternate skills. Fear reactions/fleeing protect the person from imminent danger. Explosive anger can neutralize a perceived threat.
Choice means allowing consumers to prioritize what issues will be dealt with, when and to what extent. The caveat to this merges with collaboration. While it is certainly advised to maximize consumer input and control, there are some things which may need to be negotiated. When consumers are putting themselves at risk, even before treatment starts, the chances of them engaging in highly dangerous behaviors when they are in the midst of a crisis is much greater. For example, if Johnny is drinking a fifth of whisky each night and chasing it with hydrocodone, I would certainly not recommend delving into deep, emotionally charged issues in a traditional outpatient environment. It is likely when the pain increases, so will the desperation to stop the pain. Johnny first needs to get safe—mixing hydrocodone with whisky is just a slow way of committing suicide. If he can create a support plan that includes a drastic reduction in drinking (preferably 100%) and at least 3 people who will be there to support him, then I might consider working with him on the trauma issues in outpatient. My preference is for people with dual disorders (i.e. PTSD and substance abuse) who live alone or do not have a strong support system to enter into either intensive outpatient or a 3-5 day retreat in which they can have 24-hour access to a therapist and have their medication and substance intake monitored.
Finally, empowerment means providing consumers with the tools to help them create safety, trusting them to do the next right thing and encouraging them to make educated choices regarding their recovery and their life. Empowerment means helping them find positive ways to use the energy they are currently using to try and contain their anger and devastation. In PTSD, people often have a lot of “I should haves.” They cannot change the past, but with the knowledge of what they believe they should have done, what can they do now? That is to say, they cannot change the past, but what can they do to prevent it from happening in the future and/or make ammends if they believe they have done something wrong.
Trauma informed care identifies the trauma, and all of the associated mental, emotional, physical and social changes as the primary cause of people’s mental health and substance abuse issues. Likely things will never be like they were before the trauma, but they can get better. The terapists job is to help people define what “better” looks like, provide needed skills to help the person achieve their goals and empower them to start doing the hard work necessary to recover.
Online Counseling for Anxiety, Depression and PTSD: Does it Work?
June 13, 2011 by
Over the past several years, online counseling has become more accepted in the mainstream counseling community. Nevertheless, accepted does not necessarily translate to effectively used. Let’s face it, some people just need to have the personal contact of being in a face-2-face session. However, the vast majority of people are quite comfortable with video, phone or text chat.
Some of the benefits of online counseling for anxiety, depression, PTSD and addictions include:
- Being able to connect with experts anywhere in the world
- Access to services at the most convenient time for you (8pm on the East coast is 3 pm–still during normal business hours– on the West)
- Reduced costs in terms of travel time, child care and waiting. Instead of sitting in an uncomfortable waiting room, you can be watching ESPN in your living room. This is especially important in areas like Atlanta, Arlington, Alexandria and Washington DC
- Greater anonymity. Some people do not want others to see them going in to see a counselor–for any reason. Online counseling allows people to seek services for things like depression, anxiety and addictions in the privacy of their own home.
- People with PTSD need to have a place they feel safe. Practicing some of the exposure therapy techniques with an online counselor in the comfort of their own homes can help reduce their level of hypervigilence.
- Does Fido make you feel more at ease? Well, online counseling also enables you to have him in your lap.
What are some of the considerations for online counseling for people with depression, anxiety, addictions or PTSD?
- Unless your issues are mild or moderate, many therapists will want to be able to chat with you via video such as Skype. This allows us to better assess your mental status and level of danger to yourself or others. In the case of addictions, video chat also allows the therapist to assess whether you are clean and sober.
- For online video counseling you will need to have at least DSL internet.
- If you select online counseling via text chat, it is important that you are able to type
What to expect at Gainesville-NOVA Counseling
- Your first visit will consist of an intake assessment. Your therapist will ask you a variety of questions to learn about who you are and what you hope to get out of counseling. She will probably give you three assignments.
- Your first task will be to write an autobiography. This will assist your counselor in understanding how you grew into the person you are today, when the problem started and what things make the problem worse and what things make it better. You will use a secure email account provided to you to email this to your counselor.
- Your second task will be to keep a log of the problem (i.e. how many anger outbursts, how often you have flashbacks, on a scale from 1-5 what your average daily anxiety or depression rating was.
- Pick on area of health to start working on: Getting sufficient, quality sleep; exercising, eating better or drinking more water.
- During your second online counseling session, you and the counselor will review your autobiography, your problem log and the progress you have made in improving your health. Together you will develop a service plan to guide the online counseling process. This plan will use the knowledge-skills and abilities format. Using cognitive behavioral therapy (CBT) you will be guided to learn more about the problem in general and specifically what triggers or improves your problem. Then you will identify skills that you already have which can help you deal with the problem, and enhance those. Finally, your counselor will suggest some new skills to help you cope with or alleviate the problem.
- Subsequent online counseling sessions will help you systematically go through the service plan, and make adjustments to it as necessary.
- Our goal is to help you learn how to identify the root issues of your problems, increase your motivation to deal with them and use your current strengths and skills to achieve your highest quality of life.
In short, does online counseling for anxiety, addictions, depression or PTSD work? It works if you work it. If you just show up and expect the therapist to fix it for you, then I would not expect to see significant improvement. If you treat counseling as a learning experience, to learn more about yourself and how people in general “tick,” then, yes, online counseling will probably work quite well.
What Goes on Behind Closed Doors
June 12, 2011 by
Counseling can be very intimidating for people, so in the next few paragraphs we will take a look at what happens in the therapy room.
Okay, so first, there may be a couch, but that is usually to provide seating for multiple people (i.e. your spouse or family) if they come for a group session. Most therapists these days do not expect you to lie down, nor talk about your mother. Counseling in the 21st century usually involves one of two broad approaches. The Rogerian approach is what most people think of when they envision counseling. The thought is that if people are provided with a safe, nonjudgmental environment in which to explore their feelings, they will be able to identify and resolve their own issues. This process takes more or less time depending on how long it takes to create that safety and how directive your therapist is.
The second approach is cognitive behavioral or CBT. CBT is focused on 1) What is going well and not so well in the present, 2) What does the resolution to the problem look like, and 3) What steps need to be taken to get there. While people’s past is important, because it has shaped who they are and how they view the world, the focus is on identifying (and maybe changing) how the past is impacting the person in the present. CBT deals in facts, evidence and rational thought. Many of the things we tell ourselves we must, should or can never do are good life lessons that have morphed into something irrational. To top it off, most people are depleting the energy needed for dealing with stress by not sleeping well, eating poorly and not exercising. In most cases, the first steps are the most basic. People need to start taking care of themselves and making one or two small changes in their attitude.
For example, Tom comes to counseling because he is totally stressed out and feels like he cannot do anything right. Tom’s therapist might ask him what it is he hopes would be different if he were doing *everything* right. She might point out that he seems to be holding himself to an unreasonably high standard, and would he hold his son to that same standard? What would happen if his son failed to meet that standard? Would it impact their relationship? She might also ask him to identify one or two things that he feels he must be good at, and focus on doing those things right. (Once that happens he loses the argument that he cannot do *anything* right). She will probably also ask him to start trying to get at least 7 hours of sleep each night and walking his dog for 20 minutes each night after dinner.
Okay, so you get the idea, Rogerian tends to be more conversational and free flowing, CBT is much more directive, active and problem focused. So why use one over the other? Different people process things in different ways. I am a therapist’s worst nightmare, because I need both. When I am struggling with something, I want my feelings acknowledged, then I can go about the business of problem solving. My husband, on the other hand, just wants to get down to business. He figures the sooner the problem is solved, the sooner he will feel better. Meanwhile, my best friend is one of those people who needs to talk about her feelings and use a therapist (or me) as a sounding board.
But is that all there is? No, after all the talking comes the case notes. You know, the secret stuff doctors write in people’s medical record that they do not think they are supposed to see. Let me be the first to tell you that you have every right to see those. I usually spend the last 10 minutes of the session writing them together with my patient. Why? Because it serves as a good summation of what we talked about, and then there is no mystery. My job is to help people learn why they may be feeling or reacting in a certain way, provide them the tools to better understand themselves and help them fix negative reactions/behaviors. It is not magic. Just like a mechanic can hear an engine hum and tell you volumes, so can a therapist hear what you are saying. I could learn to be a mechanic, but I don’t really want to. You could learn to be a therapist, but let’s start with listening to yourself first.
PTSD What is it Really?
June 2, 2011 by
PTSD impacts the lives of people directly and indirectly on a daily basis. It causes great physical, emotional and mental distress in the person who has it, and it also takes its toll on the people around them. I want to start by emphasizing that PTSD is a normal reaction to an abnormal situation. Let’s take a look at what PTSD really is and what you can do to deal with it. In the simplest sense, PTSD or Post Traumatic Stress Disorder can result when a person experiences or witnesses a horrific event over which they have little or no control . While it is important to remember that not everyone who experiences such an event develops PTSD, some people will. Further, if the event is repetitive such as may occur in war, child abuse or law enforcement, then the chances for PTSD to develop increase dramatically. People are just not meant to experience that level of horror on a regular basis.
But what IS PTSD? It is a cluster of symptoms which is thought to result from changes in the traumatized brain. Why is this important? Because it is vital for those with PTSD and their loved ones to realize it is not just something they can “snap” out of. It is not “just” a nightmare, and they are not “crazy.” It is somewhat interesting though to consider the symptoms of PTSD and assess how they represent the mind’s best attempt at coping and protecting the body and itself.
- Re-Experiencing the traumatic event, intrusive memories, flashbacks, night terrors
- Okay, this part really sucks, but why does it happen? It is possible that the brain is trying to assimilate something that it does not know how to deal with. It is also possible that these memories are coming back as the mind’s way of saying “Okay, that was awful. Make sure we don’t do that again.” When faced with a traumatic event, our natural response is to fight or flee. When you can do nothing, your mind cannot figure out what to do with that…which brings us to…
- Avoidance of Reminders of the Trauma
- Like reminders of pleasant things bring back pleasant memories, reminders of the trauma bring back memories of the horror and helplessness. So, yeah, it is natural to avoid reminders of the trauma. Unfortunately, reminders come in sights, smells, places, people, dates, noises etc. Eventually avoiding these things can lead the person to avoid leaving the house or sobering up.
- Subjective Numbing.
- The trauma and its effects have overwhelmed your coping skills and permeate most areas of your life. Even if you had enough energy to be happy, it just hurts too much to feel anymore. Some people just turn it all off and simply exist. Others use substances or other activities to forget or numb the pain. This numbing prevents husbands from “connecting” with their wives, parents from being emotionally available to their children and often is one of the biggest culprits for relationship problems. “He’s just going through the motions.” “He does not seem to care about anything anymore.”
- Hypervigilance, feeling jumpy and easily startled
- Many of us know people who seem to be like robots with extra sensitive sensors. They do not seem to feel anything, but they always seem to be aware of everything that is going on. For people with PTSD, they cannot relax. They are always on guard—even when they are sleeping. If you have ever taken care of a group of toddlers, you might begin to grasp how exhausting it can be to always have to be “on.” This exhaustion can negatively impact relationships that can be supportive, can increase the flashbacks and can lead to a greater sense of helplessness and irritability. In extreme cases, people can become paranoid, reclusive and overprotective. I see this a lot in law enforcement officers. One deputy once told me, “After a while, I just assumed the worst out of every black male between the ages of 18 and 25. I could be out with my family and see someone matching that description and suddenly be in cop mode. Heck, I cannot go to Home Depot without bringing my gun. ”
- Increased anxiety and emotional arousal, difficulty sleeping, concentrating, irritability and anger outbursts
- Think back to the last time you were sick or exhausted—maybe right after you brought junior home from the hospital? Were you more emotional? Did seemingly silly things stress you out? Did you get Mommy-Brain—The inability to remember more than 1 thing at a time for more than 5 minutes? All of these things can happen when you are tired. The mind itself is mounting a fight or flee campaign. It is trying to force you to get some rest. It is telling you it cannot handle one more thing (hence the Mommy-brain). When we feel this way and try to fight it, we get irritable. We often feel like we “should” be doing _____. However, we just cannot seem to get it together enough to do so. We get frustrated with ourselves and often lash out at others. (We also might be inadvertently pushing people away to stop them from putting any demands on us).
Okay, so we can see how these symptoms may be the mind’s way of protecting us, but how do we fix it. People with PTSD cannot live in a state of exhaustion and hyperarousal forever. The first step for many people is finding a way to reduce their anxiety and hypervigilance enough that they can get some sleep. Although I have known some people to push through the early stages of recovery without medications, a short course of something like Zoloft and/or BuSpar may be in order. I try to encourage people to stay away from super intense benzodiazepines like Valium or Xanax because they are highly addictive, and people with PTSD are at high risk for developing substance use issues. Other things that help are limiting caffeine or alcoholic beverages after 2pm, drinking plenty of water, exercising and setting a routine so your body knows when it is time to sleep and when it is time to be awake.
The second thing we work on is developing a strategy for handling reminders of events and flashbacks. I encourage people to know what situations are likely to trigger flashbacks and prepare before the storm. For example, one person I worked with was a trooper who watched a trucker burn alive, trapped in the cab of his truck. We talked about how hearing the tones for a priority call, driving on the interstate, smelling gasoline fumes and seeing semis could all trigger flashbacks for him. Likewise we practiced something called systematic desensitization in the office, so encountering these things would not be so overwhelming.
Systematic desensitization involves gradual exposure to a stimulus until the point people are feeling anxious or agitated. Then they are coached through a calming sequence. For many the calming sequence is a phrase or set of phrases to help them get control back. Over time, the stimulus arouses much less of a reaction. Think about the first time you asked someone out on a date. It was terrifying, but you told yourself that you could do it. Each time after that it got a little easier. Or, remember the first time you hear the tones for a hot call when you were a rookie—tunnel vision right? But after your 5th year on the force, tones aroused no more of a reaction than your morning alarm clock. Same principle here. Once people have practiced talking themselves down a few times, then when it happens in real life, they can more easily identify what is triggering them and talk themselves down.
Now this is not the end of treatment by any means. It is only the beginning. The above suggestions are simply those steps that can be taken to help you get on level ground so you can start dealing with the trauma. Oh, and for any counselor types reading this…some people prefer the word “reaction” to “feelings.” If you find that your patient is not responding well when you ask about how he felt in a situation, ask what his reaction was.
Good luck and stay tuned for more mental health tips.
Is Irrational Thinking Making You Miserable?
November 22, 2010 by
All too often we cause our misery by making mountains out of molehill.
1.Mistakes are never acceptable. If I make one, it means that I am incompetent. This is overly generalized. Would you expect your best friend or your child to never make mistakes? When they do, do you think they are incompetent? People make mistakes. Next time you make a mistake. Remind yourself that you are only human. A mistake does not mean anything negative about you, it means…you goofed. Try to find somthing to learn from it, like how you can avoid making that mistake again. Remind yourself how many other things you are competent at.
2.When somebody disagrees with me, it is a personal attack against me. Okay, sometimes this is true, especially on the internet. Nevertheless, WHY are they attacking you? Most often people lash out at others because they feel insecure. The other possibility is that you are at least partly wrong (See above). Be open to other people’s point of view. You do not necessarily have to agree. When you disagree with someone, are you personally attacking them? My guess is no. So why do you think they are attacking you?
3.To be content in life, I must be liked by all people.
Not everyone is going to like you. Get over it. If you like yourself, then it really does not matter if other people like and validate you. Many people will not like you because they are insecure or they have “stuff.” Are you really going to let their “stuff” bring you down. Take a personal inventory. Are you a good and nice person? Do people have a legitimate reason not to like you? If so, then do something about it. If you require other people to tell you you are okay, then you need to work on liking you. Take a personal inventory of all of your strengths and good qualities. Keep a journal of good things you do each day. When you start feeling bad, review your journal. Be as creative as you would like.
4.My true value as an individual depends on what others think of me. (See 3 above)
5.If I am not involved in an intimate relationship, I am completely alone.
There is a huge difference between being alone and being lonely. Even when you are not in an intimate realtionship, you are not alone. Make a list of your friends and family who love you. People who cannot stand to be out of an intimate relationship do not like to spend time with themselves. They do not like themselves. Make a list of all of the qualities you look for in an intimate relationship. See how many of those needs you can provide for yourself or get met with your friends and family.
6.There is no grey area. Success is black and failure is white.
See 1 above. We all make mistakes and rarely do we succeed perfectly at something. I remember having recitals and giving speeches in which I goofed up. My teachers always told me that if I kept going, nobody would probably notice. They were right. The speech or recital or whatever was still a success, even if I was not perfect. Part of success too is knowing your limitations. Successful people know when they need to ask for help, or simply say “I don’t know.”
7.Nothing ever turns out the way you want it to.
Well, that is a defeatest attitude. List 5 things that have turned out the way you wanted. List 5 more that have not turned out how you expected, but it turned out okay. We do not always get our way, but if we focus on what we do not have or did not get, we will always be miserable. What do you have? What positive came out of it.
8.If the outcome was not perfect, it was a complete failure. (See 1 and 6 above.)
9.I am in absolute control of my life. If something bad happens, it is my fault.
You cannot control the weather. You cannot control other people. All you can control is how you react and what you do. Bad things happen to good people. The question is, do you let it destroy you, or do you figure out how to deal with it and move on. Take responsibility only for the things that you do have control over.
10.The past always repeats itself. If it was true then, it must be true now.
The definition of insanity is doing what you have always done and expecting different results. You have the ability to change how you deal with things now. Similar situations will arise. Use your past knowledge to help you deal with them better.
