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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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How Live Your True North Began

My History With Depression

In October 2018, my therapist diagnosed me with depression after spending months struggling with chronic unhappiness. Although I seemed content from the outside, I constantly struggled with irritability, sadness, and loneliness. I paid horrible attention to my daily needs, and I spent a great deal of time wrapping myself up like a blanket burrito to hide from the world. For me, depression felt like running underwater against the current. I forgot how to be myself and often ruminated on memories of laughing easily, completing tasks with ease, and surrounding myself with good people. 

I let depression hold me captive as I fantasized about my life instead of actually living it. When I did go out, I fought through intense anxiety and discomfort. Negative thoughts swirled in my brain and told me that I was not good enough. At work, I struggled with motivation to complete tasks, crying spells, and anxiety. To make matters worse, my unhelpful thoughts screamed, “You’re a mental health therapist! You’re not allowed to get depressed!” 

My Breaking Point 

I naively expected to pick myself up from my bootstraps and get better on my own. Realistically I knew that I could not help others if I did not help myself. I struggled to navigate the cognitive dissonance associated with being a therapist who needed therapy. I felt ashamed that I couldn’t manage my depression independently, and I felt like a fraud counseling others. Instead of acknowledging that I needed help, I pretended that I knew exactly what was wrong and exactly how to fix it.

On a Saturday in September, I finally reached my breaking point. That day at work, I ran late for a therapy session with a young client, which triggered the child’s parent to feel frustrated. Naturally, I expressed my apologies and explained the nature of the delay and resumed the therapy session. However, I could not stop ruminating on what happened. Her reaction caught me off guard and triggered intense anxiety about being bad at my job. I cried, trembled, and struggled with thoughts of not wanting to be here. After processing the event and my reaction with a friend, I finally accepted that I needed help.

Finding a Therapist

I first dabbled in therapy in college after experiencing difficulty transitioning to the new environment. My therapist at the time, a lovely woman with short, black hair and a soothing demeanor. However, I didn’t feel a close connection, and I struggled to fully engage with my therapist. I eventually worked through the transition on my own. Now, though, I felt emotions I didn’t understand and didn’t know how to overcome. 

Finding a therapist was relatively easy using both Psychology Today’s “Find a Therapist” tool and the phone number on the back of my insurance card. After finding a clinician who accepted my insurance, I sat with the phone number until I gained the courage to call schedule an appointment. My therapist, Ron, was a former baseball player who changed careers after suffering permanent spinal cord damage. He had a tall and lanky frame, and his wispy gray hair framed his strong facial features. His minimalistic office featured just a few artful pictures, a cluttered desk, and a long futon where I sat week after week.

Doing the Work

It took time, but Ron helped me understand that the only thing preventing me from overcoming depression was myself. Ron described a phenomenon called “Paralysis by Analysis,” where my negative overthinking prevented forward motion and decision making. We explored the onset of symptoms and events in my life that potentially contributed to unhelpful thinking styles. With Ron’s help I realized that simply attending therapy was not enough. If I wanted my life to change, I had to take what I learned in sessions and apply it outside of the office. 

First, I left a toxic roommate situation and moved into my own apartment. Then, I spent more time with family and friends, and I engaged in more overall self care. Even though the healthy habits I created helped, I still fought against the darkness. When I hung out with others, it told me I’d rather be home by myself, doing nothing, feeling hollow. I processed this feeling with Ron, who suggested following up with my primary care doctor.  “If depression is still keeping you from coping, then maybe you should explore medication,” he said.

Finding Relief

My heart initially sank at the thought of being prescribed medication. I worried about side effects, and I worried that medication with either not work or make things worse. I didn’t want to feel more emotionally stunted that I already felt. Nevertheless, I took Ron’s guidance and made an appointment with my doctor, who took the time and care to educate me and ease my concerns. In April 2019, I began taking Prozac once a day. 

After a few weeks, I noticed a lift in mood. The heavy water that I ran through began to evaporate. Prozac helped my brain maintain serotonin, which helped my mood, energy level, and quality of sleep. I actually trained my body to eat normal sized meals again, now that it felt hungry. Better yet, I happily found that my only side effect was mild dry mouth that disappeared after increasing my water intake.  

Maintaining the Progress

I needed to find a way to keep moving forward in my depression recovery. I started by noticing how I felt when I completed certain activities. If I did something that helped me feel better, I wrote it down in a list. By paying attention to the impact of my behaviors, I learned that eating healthy, being active, and engaging in artistic forms of self expression helped me to feel my best. These habits helped me become my happiest self. 

It takes anywhere from 18-240 days to form a habit and another 60 days for that habit to become an automatic behavior. I understood that I needed to focus on making these a bigger part of my lifestyle. I ate on a Paleo diet for several months in an attempt to reset my eating habits, I adhered to an exercise plan, and I made time for activities such as painting, drawing, and journaling. Furthermore, I frequently reminded myself that progress truly is an ongoing process that never ends, and positive self talk allowed me to more easily work through challenges. 

Sharing My Journey

When I created a blog, I intended it to serve as a space to document and record my personal growth. Sharing my story helped me to hold myself accountable and allowed me to change my lifestyle more consistently, and I quickly found that there is an entire community of wellness warriors out there trying to do the same thing. I hope to empower others to ask for help in finding balance and happiness. I recognize that I will never be done growing, and I want this space to grow with me. 

Above all, I learned that no one is immune to struggles with mental health, and we all get by with a little help from our friends. Live Your True North is a safe space for healing and self exploration.

I hope you choose to join me in living well, being myself, and living my True North.

Much Love, 

Kel

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Conquering Your Inner Critic: 7 Ways to Overcome Negative Thinking

I’m not worth it. There’s no use. I can’t do it. I’ll never follow through. People won’t like me. Others are better than I am. I am not enough. I must be perfect. I am a failure. The world is evil. All people are bad.

If these phrases sound similar to your thoughts, you may struggle with unhelpful thinking patterns. Often unhelpful thoughts stem from negative perceptions of ourselves and the world around us. Negative perceptions can directly influence our thoughts, feelings, behaviors, and reactions to life events. It is unrealistic to expect that we can think happy thoughts all the time. However, we can train our brain to adopt a more realistic and healthy mindset. After all, spiraling into unhelpful thought patterns may increase feelings of stress, anxiety, and depression.

For more detailed explanation of unhelpful thought patterns, check out this psychoeducational worksheet that describes commonly used thinking errors.

After learning more about common thinking errors, keep scrolling to check out some useful tips for conquering your inner critic and decreasing negative thinking habits.

Catch Your Thoughts

Our thought patterns can eventually become habitual. This means that we can experience unhelpful thought styles without being aware of it. The first step in gaining control over our thoughts is to notice them. I encourage my Wellness Warriors out there to pay attention to your thoughts and attempt to label them. Learning about your negative thought patterns (triggers, related emotions, etc.) can give you the power to overcome them.

As a therapist, I love teaching clients to utilize an automatic thought record. This simple worksheet begins by allowing one to identify negative thoughts while encouraging further exploration and processing. To take catching your thoughts a step further, you can practice categorizing your thoughts using labels from the commonly used thinking errors worksheet.

Play out the Narrative

Often times, unhelpful thoughts can present in the form of chronic worries and “what if” statements. What if I fail? What if I get sick? What if my partner gets angry with me? Chronic worrying can send us into a negative thought spiral.

To combat this, consider what would happen if your worry came true. Ask yourself what you would do to address the situation. Developing a plan of action can be incredibly useful; if we have a plan, we naturally tend to stress less.

Practice Thought Stopping

If I tell you to think of a pink elephant, what do you think of? Most often, it is, indeed, a pink elephant.

After you catch your unhelpful thought, utilizing thought stopping techniques can help you break the cycle of negative thinking.

Common thought stopping techniques include finding a replacement thought or visual image, such as counting to ten or visualizing a scene from your favorite movie. One can also simply yell or think “Stop!” and find an alternate activity for a distraction.

Check the Evidence

There is no better way to challenge an unhelpful thought than to examine it. Remember, we are not attempting to exclude all negative thoughts. Instead, we are training our brains to think more realistically. We can achieve this by putting our thoughts on trial and exploring the evidence.

I often use this example: Imagine you are about to take a test. Your thought is, “I am going to fail.” Naturally, we may identify this thought as negative and engage in thought challenging and ask, “What evidence do I have that supports the thought that I am going to fail?” List all of the reasons why that thought might come true. Did you prepare for the test? Did you study for an adequate amount of time? Did you pay attention in class? Did you take notes? Did you study in a way that is effective for you? Do you feel focused?

If the evidence we identify supports the negative thought, it may just be that the thought is realistic. If the evidence contradicts our thought, consider that this thought is likely unrealistic and untrue.

Reframe Negative Thoughts

After we identify negative thoughts, we can reframe them to appear more balanced and realistic. Reframing simply means creating alternative, more helpful thoughts. By doing this, we begin to change our perceptions of events, experiences, or emotions.

In the earlier example, we established that the thought, “I am going to fail,” is likely true. It is important to recognize that we can still reframe negative thoughts if they appear to be true. Instead of thinking, “I am going to fail,” we might consider the reframe, “I will do the best I can.”

Take your own advice

It is so much easier to give advice than it is to take our own. Taking our own advice is challenging, but it is a critical step to overcoming unhelpful thinking habits. A helpful practice is pretending you are giving advice to your best friend. Consider the following: Would you try to get more information about what happened? Are you considering other’s perspectives? What are the different ways the situation might unfold? Finally, what advice would you give him or her?

Allowing yourself to step away from the experience and explore it objectively is amazingly simple, yet incredibly effective.

Find Gratitude

Gratitude is strongly associated with greater happiness and contentment. Practicing gratitude increases our ability to see that there is good in the world. Check out this previous post where I practice gratitude after a series of hard events and negative thought spirals.

To incorporate gratitude into our daily routines, we can keep a gratitude journal, write gratitude letters, or use visual reminders (like sticky notes on your mirror).

Practice Mindfulness

Practicing mindfulness can help relieve stress, regulate emotions, and remain nonjudgmental. Mindfulness involves simply observing, not judging, our thoughts. Imagine your thoughts are like cars passing at a busy intersection. When cars arrive at the intersection, sometimes they just pass by and sometimes they stop for a while. If we get stuck on a negative thought, we can simply engage in deep breathing while focusing on the breath, not the thought. In time, just like the cars, our thoughts pass by.

Okay, Warriors, it’s your turn: What negative thoughts have you been struggling with? How have negative thinking patterns impacted your life? What have you done to overcome your inner critic?

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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.