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

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“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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The Search for the Positive

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This post is aimed at helping you through struggles.  Not of the external variety such as financial stress or interpersonal problems, but targeting those struggles that reside within our own minds.  This is about the way that we see and interpret the events that are happening around us.  The manifestations of these struggles may be as mild as being in a bad mood or a bit grumpy for a small spell all the way to a full-blown depression that lasts for months on end.  While these endpoints are quite different, the same process underlies both results.

On a surface level, you are likely familiar with what this discusses.  People may have told you to “search for the silver lining”.  Others may have attempted to encourage you by saying that “things are not as bad as they may seem.”  Heck, even Monty Python told you to “Always look on the bright side of life.”  While well intended and on the right track, these suggestions and advice have likely been ineffective in pulling you out of the negative that clouds your thinking when you are feeling down.  Why is this?

Basically, this is prescribing the very thing that is most out of reach to you at that moment.  It’s like telling someone who is lost in the desert and dying of thirst to “just drink some water.”  When this suggestion is presented without appreciating the difficulty it entails, we are likely to reject it out of hand.  This is quite unfortunate, because the wisdom behind the suggestion being offered actually has some value in terms of the behavioral health benefits.  I will attempt to dig beneath the surface of what is being said when someone offers this type of advice and transform it from quickly discarded tropes to something that may be meaningful and helpful.

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Sleep 101: How to Give Yourself the Best Chance at a Good Night’s Sleep

               It’s been a long day.  From the time the alarm went off until this moment, as you lay your head on the pillow, you have been going full steam ahead.  Meeting the demands of your job, your kids, the household chores, the errands, and your social life has taken every last ounce of energy you have.   You expect to fall into the oblivion of sleep the moment your head hits the pillow.  But once you get there, “it” happens.  Your mind starts going, thinking about the things left undone, the things you worry about, the plans you are making.  Now sleep is just about the last thing you can do.  But you know you need to.  You start doing the math.  “Only 6 hours until the alarm goes off.  I have to get to sleep now or tomorrow is going to be a disaster.”  The more pressure you put on falling asleep, the more unlikely it becomes.

               If you can relate to this story, you are not alone.  The sleepless are not just in Seattle; sleep issues are a factor for nearly every client I see in my practice.  Thankfully, there are some very straightforward things that you can do to improve your sleep.  While these guidelines are simple, they are not easy, as many of our bad sleep habits are deeply ingrained.  However, with dedication, you can see some dramatically positive improvements in your sleep within a few weeks.

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Should I Stay or Should I Go: How to Decide What to Do With An Unfulfilling Job


Chances are, we’ve all been there: dreading to go to work the next day because we just absolutely despise our job.  Perhaps it is due to the work itself: too boring/unchallenging or stressful/overwhelming; perhaps it is due to your co-workers or boss; perhaps it is due to the clientele you deal with.  Whatever the reason, nothing can be more dispiriting and have a stronger impact on your overall well-being than being stuck in a job you hate.  The connection between work stress and negative effects on both mental and physical health is well established, even if all other aspects of your life are fulfilling and healthy.  Hopefully, these suggestions will help you to navigate what to do if you are currently in a negative work situation.  Instead of reading this article word for word (which you’re welcome to do if that is your style), I recommend that you skim through to the sections that apply to you and your particular brand of job dissatisfaction and then read the section on coping efforts.  After doing so, you will hopefully have a clear answer to the question posed by The Clash in their 1982 song “Should I Stay Or Should I Go.”

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Grief & Loss – Understanding and Coping with the Pain

There may be no life experience that is more profoundly painful than the loss of a loved one.  Unfortunately, it is an incident that we all must face at numerous stages in our lives.  Even though these are losses that we must all go through, we often find ourselves ill-equipped to deal with the depth of the suffering that we may experience.

While we will focus mainly on loss in terms of the death of a loved one, it is important to note that the grief and loss response can be triggered by the loss of anything we hold dear.  This could be loss of a valued job, moving away from a neighborhood that we were connected to, or the break-up of a relationship or friendship.

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Defeat the Worry Beast


We have all, at one time or another, been overpowered by the beast that is worry.  We are bombarded by “what if” thoughts, attacked by nightmarish fantasies about every possible thing that could possibly go wrong.  This may be triggered by hearing an awful story, a stressful situation that has arisen, or just a random thought that comes to us, seemingly from nowhere.  We feel the weight of this worry: physically, emotionally and mentally.  We end up tense and exhausted, anxious and nervous, overwhelmed and fearful.  In short, the worry beast can wreak havoc in our life.

At best, we may attempt to distract or calm ourselves from this onslaught of negativity, but there is a nagging feeling that our efforts have been futile and we will be a victim of these thoughts indefinitely.  It is difficult not to feel despair when this seems to be the case.

However, the good news is that there is a way to defeat the worry beast.  We can learn to work through our worried thoughts to where they are not out of control and creating these negative side-effects.  Before we can get to the specifics of what to do to handle worry, we first must understand a little bit about what worry is.

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From My Bookshelf: A Review of the Most Often Recommended Books


Books have tremendous power.  They can move us to feel deep emotion.  They can educate us.  They can allow us to travel back or forward in time.  They can help us address and overcome challenges we may face. There are countless excellent books available that address behavioral health issues.  This post is here to highlight some of the best of those works that I have read.

I am nearly constantly reading books from the field of behavioral health, reading novels only when on vacation.  The bookshelves in my office are full of the titles I have read and there is a special section in my bookshelves where I keep the books that I have found to be particularly enlightening and helpful.  It is from this selection that I culled my “most recommended” titles to review and share with you.  While I probably could have done a write-up on each of these books, I have limited myself to a “Top 10” listing.

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Stress Management


         Stress:  that ever-present, life-span shortening, ulcer-inducing, pull-out your-hair condition that is part and parcel of our modern lives.  If there is one issue that I seem to talk about with every client, this is it.  Stress has an immediate impact on our well-being and is therefore one of the most vitally important things to learn to manage as well as we possibly can.  This article will help you to learn more about what stress is and how to work towards minimizing its negative impact on our lives and our health.


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