Decision-Making Tool: The Weighted Pro/Con List

In a previous blog (here), I introduced a tool for helping us make decisions that have us stymied.  When we are facing a complicated decision, we can become stuck and paralysis by analysis can set in.  This post will introduce a spin on a common tool that may help you clarify which option is best for you and will hopefully help you to take steps in that direction.

We are all familiar with the tried-and-true pro/con list.  It is one of our most fundamental decision-making tools and is usually very helpful for us to see which option is more heavily weighted.  But I have often spoken with folks who have completed a pro/con list and still have no further clarity over which option is ideal for them.  Some of the choices we face are so nuanced and complicated that a traditional pro/con list may not pierce the fog of indecision.  It is these types of situations in which the following augmentation to a pro/con list may be helpful.

The procedure is as follows:

  • Make a traditional pro/con list (or multiple pro/con lists if your decision has multiple options).  Be thorough.  Brainstorm as many items as possible, no matter how small or seemingly insignificant the factor may be.
  • Assign a numerical value of 1 through 3 to each item on the pro/con list based on how important that factor is to you.  1 would indicate that this is a minor or fairly insignificant factor, not closely aligned with your values or priorities.  2 would indicate a moderate level of importance or alignment with your values or priorities.  3 would indicate a high level of importance or alignment.
  • Now we do some math.  (eek!  But worry not, it is just simple addition) We add up the numbers in each column (add all of the pros and then all of the cons).  We can now compare the ratio of pros to cons.

What we have now is all of the benefits of a traditional pro/con list with the added benefit of a numerical representation of how important and impactful each category is.  And if we had multiple choices and therefore multiple pro/con lists, we now have a way to compare these lists.  If you feel comfortable with these math concepts, you can also use the ratios or fractions of each list to further compare the multiple lists.  But even if you do not feel confident in these math skills, simply comparing the raw number is often telling enough for this to be a useful assignment.

Let me provide an example to show this process and the math involved works.  Let’s say that we are trying to compare options for an upcoming vacation.  We have 2 options: Disneyworld or a visit with family in a nearby state.  Here is the pro/con list for each option with the weighted values:

In this example, if this had been just a traditional pro/con list, the outcome would have been unclear because the lists were equal in terms of how many items were either pro or con.   But when we weighted each item, the numbers revealed that there was a significant difference in terms of which option held more important items in each category.  When we take into account our values and what we find important, a clear decision emerges. 

When this is the case, it can allow us to easily move forward with the option that was the clear winner.  But what about the scenario when both/all options still end up either closely or evenly weighted?  In those situations, I often advise people to rely on either the coin flip strategy detailed in the previous blog post (here) or some other way of randomizing the choice.  We can have fun and be creative with this (throw darts, spin a bottle, etc.) and remind ourselves that we are choosing between identically attractive options, so there is no wrong answer. I hope that you find this strategy to be useful and helpful in your future decision-making quandaries! 


The Workings of Our Minds Series: Emotions

               Many sessions with clients are spent, either directly or indirectly, exploring the dynamics of the workings of the mind.  One of the foundational understandings in this area is that there are 3 inter-related domains of our being: behaviors, thoughts, and emotions.  This post will briefly dive into the third of these aspects: our emotions.

               One powerful realization is that while we do not have direct control over our emotions, we do have a significant degree of control over our thoughts and behavior.  And, as these 3 domains are inter-related, exercising this control over our thoughts and behaviors results in a degree of indirect control over our emotions.  The implications of this understanding are profound, especially if we find ourselves struggling with issues like depression or anxiety.  It points out that we cannot snap our fingers and make a decision to feel better, but there are things we can do (either behaviorally or thought oriented) that can move us in the direction of feeling better.

               The other aspect of our emotions that bears some attention is that our emotional landscape is nuanced and multifaceted.  Therefore, we will not always have easily understood reactions and/or feelings to the events in our lives.  To respect this reality, it is often more productive to use language that emphasizes “both/and” rather than “either/or” dynamics.  When contradictory emotions arise, it can be a confusing and disorienting experience.  But if we keep in mind the “both/and” principle, it can allow us to more easily acknowledge and navigate our nuanced reactions.

               There is a wonderful analogy that captures this: thinking of our emotions like the weather.  This analogy yields 3 powerful realizations:

  1. Multifaceted – as previously discussed, we can experience several emotions in different combinations, much as the weather can combine in an infinite number of combinations.  Think of the combinations of variables of: temperature (hot/warm/cool/cold), atmosphere (sunny/cloudy/gloomy), wind conditions (still/breeze/wind), precipitation (clear/drizzle/rain/storm).  So it is with our different emotions.
  2. We cannot control the weather, but we can prepare for it and react to it appropriately.  If it is rainy, we can grab an umbrella.  If it is cold, we can grab a jacket.  So it is with our emotions.  If you are sad, you can engage with things that will be uplifting.  If you are angry, you can employ things that can help you calm down and look at things from a different perspective.
  3. It won’t last forever.  I live in Arizona and the summers are long and hot.  When it is the middle of summer and it feels like it will never end, I remind myself of the beautiful weather that we have in the winter.  While it doesn’t make it any cooler outside, it does help to persevere.  Knowing that it will not be like this forever can make it more tolerable.  And so it is with our emotions and moods.  Knowing that a depressed mood will not persist forever can make it possible to better tolerate these lows.

Keeping these dynamics of our emotions in mind can aid us in weathering the storms that difficult emotions represent.


The Workings of Our Minds Series: Contemplation, Predictions, and Fantasies

               This will be the first post in a series that explore the many different aspects of the workings of our minds.     

               Please allow me a moment to state the obvious: our minds are complex.  In my counseling practice, most of my day is spent helping people understand these complexities.  To understand the inner workings of our minds allows us to know how to best harness the power and strength that the mind offers.  I would like to focus on one aspect of our mind’s working in this post, and that is the concept of mental rehearsal.

               This concept is relatively straightforward; anytime that we are anticipating events or thinking about the future and possible outcomes, we are engaged in mental rehearsal.  Sometimes this is a purposeful act such as when we are weighing our options on how to handle a situation.  Other times it takes on the more mindless (or not purposeful) form of daydreaming or getting lost in mental fantasies.

               We often regard this latter category as benign and harmless, but it is important that we realize that our mind uses this as rehearsal for performance.  If you find that your mindless fantasies often drift to worst case scenarios and bad outcomes (such as: “I imagine that I won’t be able to reach the goal that I have in mind” or “I can picture how badly it will go when I try to talk to my coworker”), we are inadvertently preparing to make that outcome a reality.   We would be much better served to rehearse success and scenarios with a positive outcome.  Our minds can be a very powerful tool in deciding whether we approach a fearful situation or not and whether or not we successfully navigate the situation.  Our minds can keep us stuck in fear, powerlessness, and anxiety or it can help us to overcome these emotions.

               Now, that doesn’t mean that we need to take optimism to an unrealistic level to where we picture complete smooth sailing with no struggles or barriers to success.  In fact, it can be helpful to try to anticipate some of these hardships, but to focus on our strength and resiliency to cope with and overcome them.

               The main idea here is to remain mindful of the fact that our mind uses our contemplations and fantasies as rehearsal, and we are likely to perform in ways that are influenced by how we have rehearsed.

               Another way that I have heard this framed is using the analogy of going to a gun range.  One of the very first things they tell you in such a setting is to always keep your gun pointed down range.  It is an easy mistake to make to turn around and point the gun somewhere other than down range.  This presents a potentially dangerous situation where you could accidently fire the weapon and hit an unintended target.  If we think of our minds as the gun in this analogy, we want to ensure that we keep it pointed towards the intended target and not let it drift onto unintended targets.

               Our minds operate to help us execute and pursue our goals in ways that are both conscious and subconscious (meaning operating outside of our direct awareness).  Therefore, if we allow our minds to fixate on fantasies or predictions of negative outcomes, we may inadvertently activate the power of our subconscious mind to bring about those outcomes.

               Remaining mindful of which targets we are aiming our minds at can help us harness the full power of our minds to work towards desired outcomes and achieve our goals.


A “Fruitful” Analogy

I have found analogies to be incredibly helpful in deepening our understanding of situations we face in life.  One of the most powerful and fruitful analogies pertains to our social life, and that is what I want to share with you in this post.  It represents a way to think about the important relationships in our lives and how we nurture these connections.  The analogy is to think of our social landscape and relationships as a garden.  Each relationship is represented as an individual plant.

To understand and utilize this analogy, you need not be an expert on the subject; you needn’t have a green thumb for this to be useful for you.  Even as a complete gardening novice, we can grasp the idea that plants in a garden require attention and care in order to nurture a healthy and thriving plant.  The same applies to our relationships with others.  As we nurture our connections with the people in our lives, these connections become deeper and more robust.  If we neglect a plant, especially before it reaches full maturity and becomes hardy, it will likely wilt and eventually perish.  Again, this concept plays out with our friendships. 

We all are likely to have some number of long-lasting friendships that can withstand prolonged periods of no contact.  But as soon as we reconnect, it’s as if no time has passed, and we pick up right where we left off.  These are truly the treasures and centerpieces of our social garden.  While we may be giving more consistent attention to other relationships in our lives (such as our co-workers with whom we regularly interact), the deeply rooted relationships tend to be far more central to our identity.

And that is where this analogy really starts to deepen our understanding of our social lives.  Ideally, our garden will feature an array of different types of plants.  Some will be of the variety that we give attention to everyday, even though they may be relatively shallow.  This typically applies to our colleagues and acquaintances with whom we interact with every day and may or may not be friendly with outside the work confines.  Others will be the types of plants that we give periodic attention to that have deeper roots.  These tend to be medium to long time friends or family members.

Perhaps a somewhat uncomfortable truth that also underpins this analogy is the idea that all living things die.  So, too, might our friendships.  Sometimes the actual death of the person is the cause of the death of the relationship; other times it can be a falling out, a move, or just a loss of contact with the person.  We can picture the life cycle of a plant: from seed to sprout to blooming plant to mature plant to dead plant.  So, too, with our friendships (though it may be uncomfortable to acknowledge this fact). 

But this knowledge allows us to be prepared.  Both for myself and for several people with whom I have worked, an unexpected ending of a friendship can be such a painful experience.  The damage done is compounded for those who don’t have many other plants in the garden.  Ideally, we will have several plants at different stages in the life cycle.  So, even if a robust and hearty plant in our garden dies and leaves a void, it can be filled more easily with a plant that is more developed than a seedling.  If the end of a relationship strikes at a time when we haven’t even begun planting the seeds of other connections, it can be a daunting task to consider rebuilding what has been lost.  We would be looking at years before we could recover and begin to fill this void.  This is not to say that relationships are easily replaceable or that the people in our lives are expendable, but making some effort to diversify our energies in a range of relationships is often an effort that will serve us well.

This is often made more challenging if we have personalities that are low in openness (those who value tradition and routine) or if we are introverted.  However, even if this personality profile is present for you, it would be a wise investment to challenge yourself to reach out to a larger array of people than may be customary for you.

The last thing that I wanted to draw from this analogy is the idea that sometimes there are weeds in our garden.  They drain resources like water and nutrients in the soil that could otherwise be used to nourish the desirable plants in the garden.  It would be wise for you to look through your social circle (including your social media) every so often and assess if there any such weeds in your garden.  Do any of your friendships or connections leave you feeling drained or negative after interacting with them?  While it may feel complicated or threatening to do so, we are often best served by finding ways to weed these types of people out of our lives.  We don’t owe it to anyone to continue to interact with them if they are not enriching our lives.  And, yes, this even applies to family members.  Sometimes the healthiest thing we can do is to draw boundaries with these types of people and learn to preserve our own well-being.  If this is something that you would struggle to do, this might be a good indication that talking to a therapist might be helpful.

I hope you have found my favorite analogy to be helpful, useful, and beneficial in the way that you think about and care for your garden. 


How To Decide Between Two Options

We’ve all been there before: faced with a decision big or small, seemingly unable to decide which of the two options we face would be best for us.  You’ve ran through the pros and cons, considered every possible angle, but are still unable to get a clear sense of the best road forward.  You feel paralyzed to make a decision.  What to do?

I’ve discovered a solution that may seem odd, but bear with me and read through this thoroughly because it is more complex than it will first appear.  I’ve found, both in my private life and in suggesting this to my clients, that it is effective in helping solve these decisional stalemates. 

As odd as it may seem, I want you to take out a coin and assign one option you are considering to the “heads” of the coin and the other option to the “tails” of the coin and then, you may have guessed it… flip the coin.  Allow this coin flip to decide which option you will pursue.

Now, you may be rolling your eyes and realizing that there is absolutely nothing new about this approach, but here is the rub…  After this deciding coin flip, turn your attention to your gut reaction to the outcome.  Are you disappointed or happy about the outcome?  You will likely have one of these two reactions (disappointment or acceptance).  Something along the lines of “ah, man, I was kinda hoping it would be the other one” or “oh, good.”  Even if your reaction is just “ok, I guess that’s the one,” that falls into the acceptance category.

This quick exercise is an effective way to gauge your subconscious and previously undiscovered leanings in the decision you face.  I have personally used this exercise in decisions big and small; in quandaries ranging from what to get for dinner to major purchases and I have been struck by how helpful this approach is.  And even though a part of you knows the “trick” that you are playing on your mind, it still somehow remains effective in uncovering your subconscious opinion.

So, next time you are debating between two options, try this exercise out and please share your experience in the comments below.


Psychotropic Medication – Guidelines for Successful Use

Part 3: Notes on Using Medications

               This post is the third and final post in a series about medications.  If you have not done so already, I suggest you read part one in which I discussed how to recognize symptoms and walked through making the decision to take medications and part two which explores the process of starting on medications.  This third portion will explore how long you can expect to stay on your medications, as well as discussing a variety of other aspects of using medications to treat mental health issues.

How Long Should I Take These Medications?

               One of the main questions people have when considering whether or not to use a medication to address mental health issues is how long they will have to take it.  I often hear people say “I don’t want to start something that I will then have to take for the rest of my life.”  That is a valid concern, but let’s explore your options.

               Most importantly, there is no pre-determined amount of time that you should be on your medication(s).  That will ultimately be a decision that you make along with your prescribing doctor and it will vary from person to person and depend on the specifics of what you are dealing with, your preferences, and the medication(s) that are being prescribed.  That said, there are some general things to keep in mind.

               I find that people will usually have one of the 3 following experiences with medications: 1) They will go on medications for a set amount of time and then go off of them and not use them again, 2) They will plan to be on the medications for some time and then go off with the plan of going back on them if/when the need arises, or 3) To go on and plan to stay on the medications indefinitely.  I often encourage for this to be one of the things that you discuss with your prescriber when starting a medication.  Knowing what the long-term plan is at the beginning can help you to have clear expectations.

               If you plan on either option one or two, it is generally suggested that you stay on the medication(s) for a period of six months after the time where you would like to discontinue them.  The thought behind this is that it allows enough time for the changes the medications have made within your brain and body to take hold and increases the chance that your body will be able to naturally maintain these changes once the medication has stopped.

Communication Is Key

As you have read, creating a relationship with your prescribing doctor where you are working together to get you the best response from and experience with medication is a key factor.  In addition to you being clear about what you share with your doctor (in Part One of this series, I discussed being focused on and descriptive about your symptoms), there are some other things you might want to consider:  

  • Have a list of important info and questions – in the heat of the moment of your appointment with your doctor, it can be easy to forget to discuss important things.  Having these things written down is a great way to be sure that you cover all of the important information and get to ask any questions you may have.
  • Keep a record of your progress – finding ways to track your symptoms can be really helpful to your doctor.  The better the data that we can provide them, the more information they have to make informed clinical decisions about managing your medications.  There are lots of great apps that can aid you in tracking your symptoms and mood.  Your doctor may have some suggested apps or other methods that they have found helpful to them.

Beware Dr. Google

While the internet can be a great source of knowledge, it is not without a few drawbacks.  When it comes to seeking ways to be an informed consumer of medications and healthcare, a google search of symptoms or medications can yield lots of valuable information.  However, it is important that we keep in mind the nature of the information available online.  It is not always accurate and it can be a misleading representation of information.  So, keep that in mind when you turn to the google search bar.  Checking out the information you find with your prescribing doctor or pharmacist can be a useful way to be sure that you are making your decisions based on accurate and current information from an expert rather than an unverified, anonymous online source.

I Was Prescribed an “Anti-Depressant”, But I Don’t Have Depression

This is an issue that comes up fairly frequently.  If you have been prescribed an “anti-depressant” and are not sure why, it is likely because that label is not fully accurate.  It is an easy shortcut to refer to a fairly diverse class of medications.  “Anti-Depressant” is often used because the terms “Selective Serotonin (or Norepinephrine) Reuptake Inhibitor” or “SSRI” are not as easily understandable.  However, they are more accurate because they describe the way that the medication is working.  While we will skip the details, the bottom line is that “anti-depressants” are useful to treat a wide range of symptoms beyond depression.  So, it is not that you are being prescribed the wrong class of medication, it is that the medication is used to treat a variety of conditions beyond depression. 

Know Your Treatment Team

It is important to realize that there are a number of professionals who should be included in your treatment when you are using medications to treat a mental health issue.  The following is a list of the most common professionals that are involved in treating a mental health issue:

  • Primary Care Physician (PCP) or General Practitioner (GP) – This is the doctor who looks out for the bigger picture, or overview, of your health.  Some women utilize their OB doctor to fulfill this function.  Having a physical before beginning medication(s) is often recommended to ensure that we are treating an actual mental health issue rather than a physical issue that may present with mental health symptoms.  Typically getting blood work to check your thyroid, vitamin and hormone levels is in order.  Often times your PCP/GP/OB will start or manage your medications if they feel comfortable and confident in doing so.  You will typically see this provider for about 15 minutes once a month at first, then being stretched out to 3 to 6 months apart.
  • Psychiatrist – This is a doctor who is focused on medication management for a mental health issue.  They are specialists who will monitor your symptoms, response to medication(s), and any side effects you may experience.  Some people may not need to see this specialist if their PCP/GP/OB is managing the medication(s).  However, you will want to work with a psychiatrist if you are not responding adequately to the medication(s) prescribed by your PCP/GP/OB, or if there are other complicating factors in your treatment. You will typically see this provider for about 15 minutes once a month at first, then being stretched out to 3 to 6 months apart.  Some psychiatrists may see you for longer or do talk therapy as well as medication management, but that is fairly rare.
  • Counselor/Therapist – This is the professional you see who does talk therapy with you.  Your counselor/therapist helps you with the emotional, behavioral, and thought oriented aspects of your mental health issue.  You will typically see this provider for 45-60 minute sessions weekly or fortnightly.  As you will spend the most time with this provider, they can often be a good source of information for the other members of your treatment team, so you can inquire about how to have these members be able to talk to each other and work together to provide you with the best care possible. 
  • Pharmacist – This is the professional who dispenses your medication(s).  While they may not traditionally be thought of as a member of your treatment team, they are often very accessible and have good information about your medications.  You can often rely on them for answers to questions like: “What do I do if I forget a dose?” or “Will this medication interact with any of the other medications that I take?”

Balance Efficacy with Tolerability

               I think that this is the bottom line to consider when pondering if a medication should be used.  Are you getting more out of it than it is causing problems?  Often medications will have side effects.  Sometimes they will be severe enough that you will consider not taking that medication.  But you have to ask if the benefit you get from it outweighs the cost or vice versa.

Breakthrough symptoms

               If you have been stable on a medication for some time and then start to experience some of your symptoms again, this is called breakthrough symptoms.  It is not cause for alarm, but it is cause for you to contact your prescribing doctor in order to talk about this issue and see what adjustments might need to be made.

Take home message

               My hope if that these last 3 posts have helped you to make the best decision for yourself on whether or not to use medications to help you address your mental health concern.  In my experience, people can fall into a few categories where they do not get the most benefit from medication(s) as possible, so I hope you now feel prepared to avoid the following pitfalls:

  • Unsure – this is where someone does not fill their prescriptions or tart taking them due to having unanswered questions.  I hope you now feel adequately prepared to have a thorough discussion with your prescribing doctor.
  • Forgetful – this is where someone becomes hit or miss in taking their medication(s).  I hope that you now understand why taking your medication(s) consistently as prescribed is vital in getting the most from your medication(s).       
  • Blindly adhering – this is where someone is not sure why they are prescribed what they are (what symptoms does the medication target, what side effects to look out for, what benefit they can expect to see), but they faithfully take what they have been prescribed.  I hope that you now feel prepared to ask your prescribing doctor these questions in order to know the ins and outs of what you are being prescribed and can be an informed consumer.
  • Unrealistic expectations – this is where people have a skewed view of what their medication can and should be doing for them.  I often hear people say things like “if I don’t take my ‘happy pills’ I feel off all day.”  While there may be some placebo effect at play in these situations, most medications will not have a noticeable impact if you miss a dose.  Having a clear picture of what medications will (and won’t) do is a key ingredient to being an informed consumer.

Hopefully you get good benefit from your medication regiment and now feel better prepared to navigate the medical care system.


Psychotropic Medication – Guidelines for Successful Use

Part 2: Beginning a Medication

This post is the second in a series about medications.  If you have not done so already, I suggest you read part one in which I discussed how to recognize symptoms and walked through making the decision to take medications.  This second part will walk you through what to expect and how to make the most out of your work with a doctor who prescribes mental health medications.  There are some things you should know and that you can do to make your work with your prescribing doctor as successful and rewarding as possible.  We’ll initially walk through the process of beginning a medication and then explore some other notes about the use of mental health medications.

Your Initial Appointment with a Prescriber

               The most common place to begin your work with a prescriber is at your primary care physician’s (or general practitioner’s) office.  The vast majority of PCPs/GPs have a good routine knowledge of these medications and can successfully guide you through uncomplicated implementation and maintenance of these medications.  However, if you have either a complicated condition (multiple issues or a difficult to treat disorder) or a non-routine response to medications it may be best to work with a specialist (a psychiatrist).  Many times people may start with a PCP/GP and transfer their care to a psychiatrist if needed in the future.  It is often quicker and easier to get an appointment with a PCP/GP (with a wait time of perhaps a few days) than it is to get in with a psychiatrist (with wait times often over a month).

               You are likely to have under 15 minutes with your prescriber, so it is important to be prepared to talk about what you are experiencing in a manner that will lead to an accurate diagnosis of the problem.  One of the biggest keys to doing this is to focus on the symptoms you are experiencing rather than your label of what you have.  For instance, it is much more effective to say “I feel down almost all the time, I am sleeping way more than usual, and I have no appetite” than to say “I am depressed.”  While you would be right in labeling this as “depression,” your prescriber will get much more valuable information from your symptoms, as that information will guide them in their decisions as to which medication(s) are most likely to be effective for you.

               Additionally, knowing if any family members have faced similar issues and what their response has been to specific medications can also be valuable information for your prescriber.  Similarly, having a list of any medications you have tried in the past and what your response was to them is also very helpful.

               Your prescriber is likely to review the prescribed medication with you.  It can potentially be overwhelming to digest the information they may provide.  However, you needn’t try to remember every tidbit, as the information is available from other trustworthy sources (which we will review a bit later).  The main points that you should retain are:

  • What type of medication are you being prescribed (antidepressant, antianxiety, mood stabilizer, stimulant, etc.)?
  • What can you expect in the first few weeks of beginning a medication?
  • What are serious possible side-effects (although very rare) that would require immediate discontinuation and follow up from your prescriber?
  • When is your follow up appointment?
  • What to do if you miss a dose?

If these issues are not addressed, I would recommend asking them before you leave your initial appointment.

               Now that you have completed your initial appointment, it’s time to go get that prescription filled.

The Pharmacy

               Depending on your insurance coverage, mental health medications (or psychotropic medication) can be expensive.  Thankfully, your pharmacist is likely to be a veritable treasure trove of information on how to make it more affordable.  They likely know of programs offered by the drug companies, generic forms of the medication you have been prescribed and all kinds of other tricks to bring your costs down.  It never hurts to ask!

               In addition to this info on cost, your pharmacist also has wealth of info on the medication you are taking.  Sometimes if you have a simple question about your medication it can be difficult to contact your prescriber to ask this question.  (Example: “I missed my dose this morning.  Is it ok to take it tonight and then again in the morning or should I skip today?”)  However, your pharmacist is likely to be able to answer questions for you and should be a lot easier to contact in a timely manner.  They can serve as a really useful bridge from your prescribing doctor to you.

               I encourage you to not be shy about asking your pharmacist questions.  Often, we do not do this about any medications we may be taking, but it can be especially important when it comes to mental health medication.  Sometimes this is due to shame or stigma with these medications.  While privacy can be hard to come by at most pharmacies, going there at a low traffic time might afford you the best chance to have a semi-private conversation with the pharmacist.

Initial Response to Medication

               As with any medication, there may be some side-effects associated with the medication(s) you are taking.  The good news when it comes to the majority of mental health medication(s) is that side effects tend to be fairly mild and transient, meaning that they will usually go away in a few days of taking the medication(s) consistently.  While there are exceptions, especially if you are generally sensitive to medication(s), your body should adjust quickly if you keep taking the medication(s) as prescribed.  Sometimes your doctor will have prescribed the medication(s) to where you take a smaller dose at first and then gradually increase the dose as your body adjusts to it.

               The most important thing at this stage is for you to try to stay on the medication(s) long enough for them to become effective for you.  Many psychotropic medication(s) take between 4 to 6 weeks before they are fully in your system at a therapeutic level.  Sadly, many people will have become frustrated or scared by side effects in the first few days of taking the medication(s) and will stop them.  While this may be the best answer if you are having a strong or dangerous reaction to the medication(s), these reactions are rare.  Giving a medication(s) at least 2 weeks, knowing that this is the most difficult window where you are likely to have side effects and no positive effects yet, is very important.  By the end of two weeks, most of the side effects should have disappeared and you may even be starting to feel better due to the beneficial effects of the medication(s).

Follow Up Appointments

               Now that you have gotten started on the medication(s) and have gotten through the side effect window, you will likely have a follow up appointment with your prescriber at around 4 to 6 weeks after you started the medication(s).  This is a critically important appointment, so making sure that you attend it and are prepared to discuss the effects of the medication(s) will be a major step in you getting the most out of your experience with medication(s). 

               Your doctor is likely to ask you how you are doing with the medication(s).  As we discussed in the previous post, trying to be descriptive, specific, and focused on your target symptoms is your best approach.  Depending on how you have reacted and responded to the medication(s), your prescriber will continue or adjust your medication(s).  This will be an ongoing process in the coming months as you and your doctor work towards stabilization.  Your doctor may ask to see you monthly until you both feel that things are stable enough to push these follow up appointments to 3 or even 6 months apart.

               If you have an appointment several months away and there is a change in your condition or how you are responding to the medication(s), it is usually a good idea to contact your doctor’s office to request an appointment before your next regularly scheduled appointment.  It may also be beneficial to talk with your prescribing doctor about what to do if this situation arises so that you can have a plan already in place to deal with such an eventuality.


               A difficult decision may arise for you if you have started on a medication and your prescriber recommends additional medications to treat other symptoms.  Being prescribed multiple medications is what Polypharmacology refers to.  If you are not getting the desired response or benefits from your medication, you and your doctor have some options on how to address this issue. 

Often times a dosage change will be the first option.  Most medications have a range of dosages available and different “therapeutic windows,” or a range of dosages that will provide a beneficial response.  Sometimes the recommendation is to raise the medication, but don’t be surprised if the suggestion is to lower the dosage.  Sometimes the recommendations can be counterintuitive, but it is important to remember that this is why we rely on the expertise and training of our doctors.  If you are unsure of why they are recommending something, ask them to help you understand.  Having a relationship with your doctor to where you feel that you are partners in getting you the best outcome is ideal.

At other times, the doctor may recommend adding another medication.  Sometimes this is exactly what is needed, as there are several medications that are designed to be adjunctive treatments to other medications.  They can “team up” with your other medications to fully address the symptoms you are experiencing.  However, I have some clients who hesitate to go down this rabbit hole of adding medications, endlessly pursuing the perfect “cocktail” that can help them feel better.  While this does sometimes happen, having an open discussion with your doctor about your concern and exploring if there are other options will often be sufficient to avoid this kind of outcome.


Your doctor has an important role in getting you the most effective medication(s) possible, but you also have a vitally important role to play as well.  Being a consistent and reliable patient is key as well.  This means taking your medication(s) as prescribed and communicating effectively with your doctor.

It is important that you take the medication(s) as prescribed.  Sometimes people are tempted to take more or less of a medication if they are not getting the response they desire.  While this temptation is understandable, adhering to your prescription as written is part of how you take an active role in managing your medication(s).  If you feel the need to alter your prescription, this is a great time to reach out to your prescribing doctor to discuss your concerns.  Furthermore, you can always seek an opinion from a second physician if you are feeling unsure of your medication management.

In the Next Part of the Series…

               In the third and final part of this series of posts, I will discuss some final points regarding medications including: how long to be on your medication(s), the members of your treatment team, and a few other final points.


Psychotropic Medication – Guidelines for Successful Use

Part 1: Should I Take Medications?

               One of the most common and difficult issues that comes up for my clients is whether to consider using medications to aid them in addressing their issues, and if they decide to do so, how to do so effectively and safely.  The set of medications that treat psychological issues have many names, but as a group, they are collectively referred to as psychotropic medications.  (I will also use the term mental health medications interchangeably.)  Due to the complicated nature of this topic, this will be a multi-part blog-post.  Some of the factors that make this a complicated topic are: common misconceptions about medications, stigma, and difficulty using our current healthcare system.  Each of these will be addressed.

               To attempt to have some structure to this discussion, we will walk through the process of getting on medications in a chronological order.  Therefore, if you are at a different phase in this process, you may wish to skip ahead to the stage that applies to you.  However, there are likely to be helpful pieces of information even in sections that may not directly apply to you.

               As a quick disclaimer: this discussion of medication is designed to be informative but is no substitute for direct medical care and treatment.  You should heed the advice and direction of your prescribing doctor when taking or considering the option to take a medication.

The initial question

               The most basic question that we can start with is: “are medications going to help me in dealing with what I am experiencing?”  To answer this question, it is most helpful to be clear about what issues you are experiencing.  While not a comprehensive list, the following issues are the most common things psychotropic medications treat:

  • Depression or other mood-related issues including:
    • Depressed mood
    • Energy level
    • Motivation
    • Irritability
    • Concentration
    • Mania (Bipolar Disorder)
    • Impulse control issues
  • Anxiety
  • Psychotic symptoms (delusions, or thoughts that are not based in reality)
  • Attention issues/hyperactivity

If you are experiencing issues in any of these areas, medications may be beneficial for you to consider.  In addition to medication, counseling and lifestyle changes are also interventions that you should strongly consider.  One of the biggest mistakes that can be made is to expect for a medication to fully fix a psychological problem.  Very rarely are these issues purely biological (which is the only aspect a medication can address), therefore, only relying on medications leaves multiple contributing aspects unaddressed.  A handy way to remember this is the saying that you likely need “skills and pills” to address these issues.

Oftentimes people will prefer to avoid taking medications and there is nothing inherently wrong with this approach.  However, if you have given a good faith effort to counseling and lifestyle changes without experiencing a reduction in your symptoms, then you are likely to benefit from considering adding the use of medications to your current interventions.

Confronting stigma

               A significant barrier to the effective use of medications is often perceived stigma around using mental health medications.  Stigma around mental health issues and the medications used to treat them arises from a time in the not too distant past when mental illness was viewed as a sign of demonic possession which was something that happened primarily to bad people or those who had sinned.  While we thankfully have come very far from this perception, the idea that there must be something wrong or bad with someone who is suffering from a mental illness has lingered.  With this limited and skewed understanding of mental health issues, it is clear why people would go out of their way to distance themselves from those experiencing these issues or would even go to great lengths to hide them if they were experiencing these issues.  Fortunately, we have evolved in our understanding of the nature of mental health issues to be able to view it as a multi-faceted issues that has biological, psychological, behavioral, and social aspects. 

Stigma can come in a few varieties:

  • Internal – this is your own view and judgment on medications and those who use them.  If you view using medications as a sign of weakness, this will be a major barrier for you to consider them.  I often encourage people to challenge this by viewing mental health issues the same as you would consider any other medical issue.  I often ask the question, “Is it a sign of weakness for someone with diabetes to use insulin or other medications that control blood sugar levels?”  This is invariably answered with “no.”  It really is no different with psychotropic medications.  In fact, it often requires a large degree of bravery to be able to acknowledge and admit the need for help in this area.
  • External – these are the views and judgments from others.  They can come in two forms:
    • Actual – this occurs when others make direct negative comments about your, or other people’s, use of psychotropic medications.  This can range from subtle to overt.
    • Projected – this is where you assume that another is having a negative evaluation of your use of mental health medications.  You may infer this from a facial reaction or some other sign, but the key here is that it is an inference.  The important thing to understand about projected stigma is that it is actually your internal stigma that you are projecting onto another.  Consider the analogy of a movie projector that projects images onto a blank screen.  You are the movie projector, and the other person is the blank screen.  So, while the images seem to be on the screen, they are actually originated by the projector.  The other person may or may not actually have a negative judgment about medications, but, unless it is actual external stigma as described above, it is important that you recognize and own the stigma as your own.

So how do we combat stigma when it is present?  Part of the answer is in education.  Education efforts need to take place in three arenas.  The first is with the person who is dealing with the mental health issue.  Ideally, prescribers take time to educate people when they are initiating treatment, both on the medications and the targeted illness.  However, this often does not happen.  This is one way in which counseling can be helpful.  A counselor is often afforded more time than a prescriber to explore any stigma, either internal or external, that may be present and can provide education on the targeted illness.

The second arena where education is needed is in the family.  Family members are one of the most common sources of stigma, either intentionally or unintentionally.  Most often, this is due to misperceptions and/or misinformation about medications and mental illness.  Family members may also struggle with their own genetic predisposition to mental illness and may be unwilling to acknowledge their own mental health struggles.  Organizations like NAMI (National Alliance on Mental Illness) in the USA provide great resources for families to educate themselves. 

The final arena is in our communities at large.  From our workplace to our friends and any other people with whom we may come into contact, these are all opportunities to educate others on mental illness.  While judging the appropriateness of sharing information with certain people (it’s likely not appropriate to share things out of the blue with the clerk at the grocery store), there may be opportunities to educate others.  One such opportunity is if you hear someone sharing misinformation or speaking in a stigmatizing fashion.  Providing accurate information to correct misconceptions or politely confronting those who stigmatize mental health issues is an important step to continue to make progress in this area.

A good thing to educate yourself and others on is just how widespread mental illness and use of medications are.  Searching the websites of NAMI ( and the National Institute of Mental Health (NIMH, will provide both overall numbers as well as specific numbers based on certain disorders.  Knowing how common these issues are can help to normalize your experience as you confront these issues and knowing that you are not alone in these struggles can be comforting.

               At this point, we will assume that you have made the decision to start taking medications due to identifying symptoms that medications can address and have overcome whatever stigma may have been present.  The next blog post will delve into how to handle your initial consultation with a psychiatrist.


Getting Around to Talking About Procrastination: 3 Simple Principles to Stop Delaying and Getting It Done

I have intended to write this post for 3 months now.  My process has been as follows:

Identify the topic – check.

Brainstorm an outline of what I want to say – check.

Stagnate – check.

Stall – check.

Finally get around to actually writing – check.

Granted, other things have come up that demanded my attention.  Some legitimate, some mere distractions, some blatant attempts to not do the thing that had been hanging over my head.  This is the very essence of procrastination.  I put off to tomorrow what could have been done today.  I know better.  I counsel and advise others on how to avoid this pitfall.  I know the short-term benefits of avoiding are not outweighed by the long-term consequences that will follow.  Yet none of these chiding thoughts prodded me into actually writing this post.  Up until this moment as I write, I had not followed my own advice.

I have been on both sides of the procrastination battle; both as a victim to the temptations of delay and as a victor over the siren’s song of postponement.  I can say that being the victor is far more satisfying and rewarding.  Following the three simple principles that follow will help guide you to be victorious over procrastination more often than you fall victim to it.  I know firsthand: it is simple, just not easy.  But it is well worth the effort.

Front Load the Work

We often have a lot of things that need to be done and a lot of things that we could do that would be beneficial, wise, and productive uses of our time.  Some of them are responsibilities and some are things to unwind and relax.  Most likely, the items on the responsibilities lists are the ones that will be put off to some other time.  We prioritize other activities over what should be done.  How this typically plays out is that we will engage in some other (less important) activity, all the while feeling the weight of the thing we are not doing hanging over our heads.  This tends to rob us of some of the enjoyment of what we are doing.  It is likely to be hard to fully enjoy going out with our friends if we know that we really needed to be working on a report that is due the next day.

The fix for this is to “front load” the work.  Do the thing that needs to be done first and then you can fully enjoy the rest of your time, free of the burden of knowing that work awaits you once you are done.  You will feel good about getting the to-do item accomplished and then you can engage in whatever activities that follow with a clear conscience.

If you get into the habit of doing the work first and then playing afterwards, you can achieve a balance to where you are fully productive and fully engaged in fun and fulfilling activities as well.  This balanced approach will help prevent you from feeling burnt out or overwhelmed.


Present Me and Future Me

               The second principle is to remember that future me is not going to be any more motivated, energetic, or capable than present me.  To understand this principle, you must first understand that you hold two versions of yourself in your mind at any given moment.  The first is “Present Me,” which is the you that you are currently experiencing.  Present Me is currently reading these words.  Whatever you are thinking, feeling, and doing in this moment makes up Present Me.  Future Me is the idea of what you are going to be like outside of this moment.  You may be thinking that Future Me is going to cook dinner, or go to that movie you have been wanting to see, or take that vacation you have been dreaming about.  Future me gets to do all sorts of things, both pleasant (like the movie or the vacation) and unpleasant (like chores, pay bills, and get root canals).

Problems with procrastination occur when we start to assign too much stuff to Future Me.  We may begin to think that Future Me is going to develop super-powers of super-human will, motivation, and energy.  Or at least Future Me would need to develop these super-hero abilities in order for them to accomplish all that is being assigned to them.  When there is this rift between what Present Me and Future Me is capable of, we are deep in the waters of procrastination.  And we are likely drowning in those waters.  We need to understand that Future Me is going to feel exactly like Present Me does.  Future Me does not like doing dishes any more than Present Me does.  Future Me does not possess an amazing ability to balance the checkbook any more than Present Me does.

Future Me and Present Me are the same person.  When we understand this, we may be less likely to heap loads of responsibilities onto Future Me.  If you use the first principle of front loading work, Present Me can accomplish some things and then go and have some fun rather than Present Me hogging all of the fun and Future Me getting the raw end of the deal.


Motivation Follows Action

               The final principle deals with how we perceive how we get things done.  When asked, people will often respond that they do something when they feel like doing it.  “I get the inspiration to accomplish something and then I set about doing it.”  Some things will happen in this sequence.  But if we are procrastinating, it is this process that has gone awry.  We are waiting to feel the motivation to do something before we start doing it.  And typically, that motivation just ain’t coming any time soon.  This way of thinking is what I call “action follows motivation.”  You can think of it as motivation being the engine and action being the trailer that is pulled along by the engine.

This simply does not work when we are faced with a procrastination problem.  In this case, we must force ourselves to flip the sequence and realize that motivation will follow our action.  When discussing this, I often think of how I feel when there is a sink full of dishes from dinner.  I don’t really want to do them, but I know that I want them to be done.  If I wait around to feel like doing the dishes, I would probably still be sitting here with a sink full of dirty dishes.  So instead, I start doing them and, after about the second plate, I realize that I am motivated to finish the job.  It feels good to be making progress towards being done with this chore and I am looking forward to when I can go sit down and enjoy some quality time with my family and unwind.  What has happened here is that motivation has followed my action.  And when you think about it, the flipside of that is that being unmotivated follows inaction.  The longer we avoid doing the things we know need to be done, the less motivated we feel.

Procrastinate No More

We will all likely struggle with procrastination from time to time, but now you are armed with these three principles to assist you in combating procrastination.  It may have taken me three months, but I eventually took my own advice, kept these principles in mind and completed this post.  And I feel much better for having done so.  I wish you the same success!

Edited by Shirley Sachs

Uncertainty: The Only Certainty In Life

Image result for college professor female

“If you want to be successful in this field, you’d better learn to love ambiguity.”  A professor said this to her class 12 years ago.  As a student in that class, I can almost hear these words today as clearly as they were spoken over a decade ago.  This has stuck with me because it has proven to be true.

In my job I work closely with people, come to care for them deeply, watch them struggle and triumph.  And then, in the majority of cases, we stop seeing each-other.  This is the natural progression of therapy.  In the cold clinical sense it is meet, assess, treatment plan, intervene and then terminate.  I usually invite (if not outright plea for) follow-up calls, periodic check-ins.  Perhaps naturally, seldom is this invitation accepted.  Here is the ambiguity that my professor identified.  Did this person maintain their progress?  Did that issue ever resolve?  What happened with their spouse?  These questions rarely receive an answer.

But this post is not about me or the ambiguity that therapists encounter.  It is about how we all come to terms with the ambiguities and uncertainties in our own lives.

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