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What No One Tells You About Being a Therapist

A therapist’s office is intended to be a safe, warm space that allows for others to express and process patterns of thoughts, feelings, and behaviors. It’s a place where people go to feel better. As a helping professional, I have the privilege of being part of the personal development and growth of my clients. I am deeply passionate about what I do, and I’ll be the first one to admit that I still get goosebumps whenever a client experiences an “Aha” moment. That being said, the mental health profession is not one without challenges.

According to the Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS), it’s estimated that about 22% of adults in the city are diagnosed with Depressive Disorder, 16% of adult Philadelphians experience frequent mental stress, and 13.8% of teens experience suicidal ideation.

To paint a clearer picture, these statistics mean that in Philadelphia 1 in 5 adults are diagnosed with depressive disorder, and 1 in 7 high school students have reported seriously considering suicide. These startling numbers are not counting the undiagnosed or unreported cases. These rates have remained consistent within recent years, with the exception of a wild increase of opioid-related deaths and ER visits for drug overdoses. With the growing severity of the opioid epidemic in the United States, an already overwhelmed system seemingly only has so much wiggle room before it breaks.

Community Behavioral Health (CBH) is a non-profit corporation contracted by the City of Philadelphia to provide mental health and substance use services to Medicaid recipients in Philadelphia County. There are about 144 Community Behavioral Health organizations in Philadelphia, and I have worked for and with many of them. Although I love the work that I do with clients, working in community agencies has created an entirely new perspective on how therapists and participants are treated among the Community Behavioral Health system….. and I think we all deserve better.

I remember learning about proper ethics and counseling techniques in my graduate program, bright eyed as I geared myself up for a future as a helper. Looking back, it seems so naive for me to have thought that it would be easy. Admittedly, I often wish I could go back to school and pay closer attention to discussions on how to avoid burnout, but sometimes it seems that in the community behavioral health field, burnout is inevitable. Although it would not have changed my choice of profession, I wish I had been more prepared for the community mental health world.

Here’s what I wish I had known:

  1. There are not enough mental health therapists in the community behavioral health system. It seems as though a major theme within the therapist community is the feeling of being overwhelmed by a bogged down system. Community Behavioral Health has an incredible amount of participants in need of mental health care and not enough wo/manpower to provide the quality of care necessary to treat severe mental health symptoms. This means that the large number of participants receiving services are divided among the limited mental health professionals that exist, meaning higher burnout rates for therapists.
  2. There is a major focus on productivity. Full time therapists are given a certain number of clinical hours that they must provide per month, typically called productivity. For example, in my organization, the month of October held 160.63 available treatment hours. I need to achieve 66% of that, meaning I needed to provide at least 106 hours of therapy to meet productivity expectations. If I don’t, I risk being written up. So when we get into the nitty-gritty of things, my work performance is not determined by the quality of therapy I provide, but by the quantity of services I provide. Where I try to validate myself, it is sometimes hard to focus on my successes with clients when I am consistently reminded of “my numbers.” It also makes it more difficult to be understanding when clients cancel, which is often framed as one less hour toward productivity.
  3. Many organizations are turning to fee-for-service. Fee-for-service is pretty self-explanatory. In fee-for-service positions, therapists only get paid for the sessions they complete. This means that if a client does not show up, the therapist will either not get paid, or will get paid a small percentage of what they would have received. Oh, and fee-for-service therapists don’t get paid for the paperwork or outreach they do…. and let me tell you, in this field there is always a lot of paperwork and outreach to do.
  4. Community behavioral health is behind. Think about all of the ethical guidelines, evidence-based practices, and sensitivity training we learned about in school. Now, try to imagine trying to implement those practices in an organization that always seems 20 years behind the present status quo. This isn’t necessarily community behavioral health’s fault. It simply takes time to roll out new methods given the amount of education and training they require.
  5. Sometimes people don’t listen. I feel like I can talk about ethical treatment and appropriate care until I’m blue in the face, and it still doesn’t feel like I am heard. I often find myself thinking of therapists as the nurses of the mental health field– we have an incredible amount of knowledge, have spent years studying the subject, and care deeply about making sure our clients are receiving proper care… and it still feels like we are spinning our wheels just to be heard and respected.

And finally, none of this would matter if we didn’t care. Professionals typically don’t join the mental health field if they don’t care about the well being of others. This makes it even more frustrating when we can see that the overall focus is not on the quality of care we provide, but instead, on the success of the business. Although I can recognize that the business aspect is important, it just does not feel right to put the needs of the business before the needs of people. Helpers feel passionately about the injustices within social systems, because we care about the outcomes of the people we work with. It can be incredibly frustrating to see the above factors as barriers to doing what we love most– helping people.

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What Is Depression?

Depression is as prevalent as the common cold. The Anxiety and Depression Association of America estimates that 264 million people around the world live with depression. Most people experience sadness, loneliness, or fear. These feelings are a normal part of life. However, depression involves clinical levels of low mood that impacts a persona’s ability to function within their daily lives.

Clinical depression is characterized by the following symptoms: persistent depressed mood, diminished pleasure or interest in activities, decrease or increase of appetite, insomnia or hypersomnia, psychomotor agitation or slowing, fatigue or loss of energy, feelings of worthlessness or guilt, diminished ability to focus or think, indecisiveness, and recurrent thoughts of death or recurrent suicidal ideation. The Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5)’s diagnostic criteria states that 5 or more of the above symptoms must be present within the same 2 week period.

How Is Depression Different From Sadness?

Most people experience intense sadness or grief. These feelings can impact a person’s ability to function, and they can also exist for at least 2 weeks. However, when we experience something difficult, sadness and grief are natural reactions. Sadness and grief share some characteristics with depression, but they are temporary and typically fade with time. Usually, sadness or grief involve moments of relief and have no significant impact in thought processes or behaviors.

Sadness is simply one symptom of depression. The DSM-5 indicates, “Responses to a significant loss (e.g. bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered.”

Who Is At Risk For Depression?

Mental illness does not discriminate. Anyone can experience symptoms of depression at some point in their lives. However, there are some factors that put others at more risk of depression than others. Biochemistry is a well-known factor in determining whether or not someone will experience depression. Individuals with depression often experience a deficit in certain neurotransmitters in the brain. This explains the effectiveness of medications that help to balance chemicals in the brain.

Although it is commonly believed that depression is the result of a chemical imbalance, the condition is much more complex. Genetics can also play a role, meaning that individuals with a family history of depression are more likely to experience depression. Research shows that there is also a connection between personality and depression. Studies show that difficulty coping with stress, limited engagement in community and environment, and limited insight may increase risk of depression. Environmental factors, including exposure to community violence, traumatic experiences, or limited access to resources, can also be predictors of depression.

When Should Someone Get Help?

Sometimes the line between between depression and sadness is clear, but sometimes it is not. For example, you may feel nervous while giving a presentation, but that doesn’t necessarily indicate a mental health disorder. However, becoming so overwhelmed with nervousness that you cannot follow through with the presentation may indicate a need for help.

If symptoms interfere with your ability to function within your daily life, it may be time to seek help. Challenges maintaining relationships, engaging in social settings, or performing in work and school can indicate a mental health disorder. Mental health disorders can also be responsible for changes in personality, energy level, and mood. Typically, symptoms that last 2 weeks or longer should be evaluated by a professional to determine the appropriate care. However, these are not the only situations during which to seek help. Anyone can get help at any time. If you feel the desire for therapeutic support, explore it regardless of how your situation compares to others!

How Is Depression Treated?

There are many types of treatments for depression. Just as depression looks different for everyone, depression treatments may have different effects for each individual. The most effective treatment method for depression is a combination of psychotherapy and medication. Some common forms of psychotherapy that are effective in treating depression include cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), or psychodynamic therapy. One might also seek support groups, group therapies, or community engagement programs for added support.

Research shows that the relationship between the clinician and client is the most effective tool in treating mental health disorders. That being said, it is important to have an open mind and to remember that effective therapy requires the ability to trust the clinician. If you seek support and find limited connection with the clinician, don’t be afraid to explore other options. Read about alternative treatments here!

How Can Someone Find Help?

Especially during times of high need, finding help can unfortunately require time and patience. Psychology Today has a great Find a Therapist tool, where you can limit search based on insurance, areas of practice, or location. Most insurance plans also have a website where you may consult your provider directory. This is a good way to ensure that a clinician accepts your insurance. It is a good idea to look more closely at your insurance plan to determine if your plan limits the amount of sessions you can attend.

To find help, it can be helpful to ask someone your trust. A referral from a friend, colleague, or medical professional is a good way to find a clinician who may be a good fit for you. Additionally, online resources, such as Anxiety and Depression Association of America, are a helpful way to navigate the mental healthcare system. It can also be a good resource to learn more about types of depression treatments to determine the modality that may be most helpful. Make sure you check out this page with information on support groups and additional resources for navigating the mental health system during a pandemic!

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Can Yoga Help Depression?

Yoga students may present with a variety of physical health concerns, such as chronic pain or injury. As a yoga instructor, it is important to become familiar with student histories so that the teacher can ensure the yoga studio remains a safe space for students. Overall, engagement in yoga practice has been consistently increasing in frequency across the United States. To accommodate the growing practice, yoga sequences can be specifically adapted to serve various populations, such as older individuals, children, or those with physical ailments. This makes it critical that a yoga teacher learn about students in order to provide them with the safest and most inclusive practice (Stephens, 309).

The practice of yoga can be utilized to address and treat many ailments, such as physical health concerns. While some individuals use yoga to treat physical conditions, some find that yoga is a positive tool in treatment emotional and mental health conditions (Stephens, 324). The physical and mindful components of yoga are thought to be meaningful practices for those experiencing emotional disturbances. Students of yoga can utilize the mind-body connection to address mental health concerns, such as anxiety and stress. Breathing techniques and mindfulness can assist in decreasing anxiety. Most commonly among mental health conditions, Americans utilize yoga practice to manage symptoms of depression.

Depression is one of the most common psychological disorders and involves symptoms such as changes in mood, low energy and motivation, loss of interest in preferred activities, increased irritability, physical aches and pains, and changes in sleep and appetite. These symptoms can be acute and can severely impact one’s ability to manage areas of daily life, such as nutrition and sleep. Though depression is incredibly is incredibly common, the causes of depression vary among an array of environmental, biological, or psychological factors. Traditional, evidence-based treatments for depression include medication management and/or psychotherapy. However, there are some barriers that individuals may face when seeking to participate in traditional mental health treatments. Many individuals never receive formal treatment for depression due to various limitations, such as limited access to resources, stigma associated with mental health treatment, or experiencing unwanted side effects of medication (Bridges & Sharma). Additionally, lack of follow through with treatment may be due to financial stressors or poor connection with treatment teams (Prathikanti, et. al.).

Depression that is left untreated may result in worsening chronic symptoms, such as suicidality or psychosis. These symptoms can impact career, education, family life, or interpersonal life, which can cause an individual intense distress. On average, a depressive episode can last from 6-12 months, with some individuals experiencing symptoms of chronic depression lasting several years. Although patterns of depression vary between each person, most individuals who experience one depressive episode in their lives will eventually experience a recurrent episode (Prathikanti, et. al.). The high relapse rate among those who experience depressive symptoms may also contribute to the lack of follow through with traditional treatments.

It is well known that yoga promotes a variety of physical health benefits. Regular yoga practice can improve flexibility, lower heart rate, decrease stress and anxiety, and reduce aches and pains (Bridges $ Sharma). It can also assist in digestion and other areas of physical wellness. However, yoga can also be beneficial in promoting emotional wellness. Where traditional mental health therapies focus on teaching mindfulness, deep breathing techniques, and relaxation skills, these are also important foundational aspects of yoga (Prathikanti, et. al.). This similarity in techniques means that yoga involves many of the skills taught among traditional therapies that treat depression. For example, mindfulness-based therapy focuses on deep breathing, relaxation skills, and mindfulness toward the present moment. These are also factors that are of focus in yoga practice.

The goal of yoga in minimizing symptoms of depression is to assist students in reaching santosa, or contentment. Traditional yoga views depression as a result of an individual experiencing either a rajastic state or a tamasic state. A rajastic state is one in which an individual experiences anxiety and restlessness. An individual experiencing a rajastic state may benefit from yoga practice that includes a slower flow with long holds. Meditation and calming breaths utilized in these types of sequences can assist in alleivating troublesome feelings of anxiety and restlessness. A tamasic state is one in which an individual experiences low energy and hopelessness, which are symptoms most commonly reported among individuals experiencing a depressive episode. An individual experiencing a tamasic state may benefit from a yoga practice that involves more active and stimulating poses, along with encouragement to keep the eyes open and awake (Stephens, 324). This appears to counteract the low energy experienced by individuals struggling with symptoms of depression.

With the growing rate of public interest in yoga, research related to the efficacy of yoga in promoting health and wellness has dramatically increased. According to Pathikanti, et. al., yoga may be a valuable alternative treatment in addressing depression. During a study of the efficacy of treating clinical depression using yoga, 38 individuals were screened to participate in an 8-week Hatha yoga program. These individuals were those who met the diagnostic criteria for major depressive disorder and were not currently receiving any treatment for the condition. Individuals were randomly divided into two groups: a yoga practice group and a yoga education group.

Those who participated in the Hatha yoga practive group participated in a 90-minute yoga practice two times per week for eight weeks. This practice group included breathing techniques and poses that promoted relaxation and mindfulness, with the same yoga sequence being used for each session. The yoga sequence used featured chest-opening poses, which are traditionally incorporated into yoga practice to decrease feelings of depression. The group who participated in the education group completed modules related to yoga history and practice for 90 minutes two times per week. Depression was assessed every two weeks throughout the research study using evidence-based depression scales (Prathikanti, et. al.).

Results indicated that depression decreased among the group that participated in yoga practice when compared to those who participated in the education group. However, researchers noted that the differences in rates did not change until the eighth week of practice, suggesting that consistent and prolonged yoga practice is most effective in promoting positive mood changes. The delay in results also suggests that one requires time to adequately learn and practice yoga poses and skills in order for their practice to be effective in alleviating depressive symptoms (Prathikanti, et. al.).

In another study of the efficacy of yoga in treating depression, a literature review was completed to compare outcomes among several research studies that explored the use of yoga in depression treatment. Eighteen published studies, all of which took place in various yoga studios, were assessed. The most common of these schools were ones that primarily taught from the school of Hatha yoga. In this literature review, interventions that were over the course of 6 weeks or more on average were studied, and measuring tools were used to monitor depression over the course of practice.

These schools utilized different structures of practice over the course of the research. Most schools encouraged participants to practice yoga at least once per week for a duration of time ranging from 12 minutes to 90 minutes (Bridges & Sharma). Although numerous differing yoga methods were used in these studies, results showed that all methods, even those in shorter duration, included participants who reported reductions in depression levels. Although, there was no evidence that showed that one method might be more effective than the others in reducing depression symptoms the study could suggest that regular practice of yoga and meditative skills may relate to decreased depressive symptoms. These results indicate a growing need for more research into the efficacy of mind-body interventions in treating clinical depression (Bridges & Sharma).

More specifically, the literature review found that a study by Marafet, et. al., researched an experimental group and a control group. The experimental group participated in three 60-minute yoga sessions, which included breathing exercises, meditation, relaxation, and physical exercise, while the control group participated in assessments only. The results of the study showed that those who participated in the yoga group experienced markedly decreased depressive symptoms. The outcome determined that yoga interventions were effective in decreasing depressive symptoms. Therefore, while traditional therapies and interventions are recommended, mind-body interventions appear to be an effective complementary interventions (Bridges & Sharma).

Depression is the most commonly diagnosed mental health condition. Although many individuals struggle with symptoms of depression, many do not receive traditional evidence-based treatments to assist with alleviating symptoms. However, studies show that regular practice of yoga and meditation may assist in minimizing symptoms of depression. This may broaden access to mental health treatment among those who experience barriers in accessing traditional therapies. Several research studies show that regular yoga practice has been effective in alleviating depressive symptoms.

References:

Bridges, Ledetra and Manoj Sharma. “The Efficacy of Yoga as a Form of Treatment for Depression. Journal of Evidence-Based Complementary & Alternative Medicine, 30 June 2017.

Prathikanti, Sudha, et. al. “Treating Major Depression With Yoga: A Prospective Randomized, Controlled Pilot Trial.” PLoS One, 16 Mar 2017.

Stephens, Mark. Teaching Yoga: Essential Foundations and Techniques. North Atlantic, 2010.