writing

What is a first visit with a therapist like anyway?

So, yes, people often do not know what to expect when you visit a therapist’s office.

It can be an awkward, vulnerable, and just a very different sort of conversation than you usually have. If you were going to a general practitioner, then you may get asked questions about your injury, your cough, the possible infection. There are blood tests and urinalysis. And the subject of the visit generally stays there.

Therapy can feel like a conversation, but a conversation with a purpose.

On a initial visit, you will typically be asked to fill out a questionnaire that asks you about your symptoms (e.g. sadness, anxiety, fears, sleep, appetite, substance use, other behaviors). There will be questions about how you grew up (or stressors in your current growing up). There may be questions about any sort of family history of substance abuse, mental illness, or trauma, as we know that we are a complex combination of genetics and environment.

Then the conversation begins.

And while some of the questions may be difficult, remember that this person is trying to help in the end. Oftentimes you may not say everything in the first session; and that is OK. In fact, there is a phenomenon called “flooding” where sometimes people tell everything in the first session, feel that they have then shared too much, feel embarrassed, and then do not return.

Therapists are trained professionals and will typically guide the conversation in such a way as to get the information they need to make a diagnosis, but also begin to guide you toward a plan for how to tackle the difficulty at hand.

As you get to the end of the session, there is usually a summing up and a plan.

Most therapists in the state of Georgia can diagnosis mental illness. These are illnesses such as depression, anxiety, schizophrenia, bipolar disorder, and ADHD. While therapists are able to diagnose, there are some entities such as school boards and government agencies that may require further testing to meet their requirements. So by the end of your session, you may have a preliminary diagnosis. And I use the word preliminary, because diagnosis of mental illness does change over time as new symptoms present themselves and some initial symptoms become less important.

Mental illness is more challenging to diagnosis because most of the information is based on history and questions, not blood tests and brain scans.

And while there are very good folks working on using blood tests and brain scans, it is not technology that is widely available or financially accessible for most folks at this point.

So at the end of your first session, you may have a referral to a psychiatrist or back to your general practitioner so that you can discuss medication for an illness or other tests to rule out other possible causes of your symptoms like thyroid disease or diabetes. We may have a discussion about certain lifestyle changes that we know can help us physically as well as mentally, such as changes in diet and exercise. And your therapist will likely give you some homework that involves noticing certain thought patterns that may be contributing to your symptoms or a writing assignment like “the miracle question.”

It is OK to ask your therapist about these next steps, how long they expect treatment to last, and what you can expect as a patient/client.

And somewhere in this process, you should be given in verbal and/or written format some idea of privacy practices, about what to do in case of an emergency, and when you can schedule another appointment, if you wish. Because this last part, is potentially the most important. There is good evidence that the “type” of therapy is less important than that you feel comfortable with and trust your therapist. While their skills and knowledge base are what got them there, if you do not feel that you have a good, trusting relationship with that person, the most knowledgeable and skilled provider will not help near as much, if at all.

Turning the Other Cheek

Matthew 5:38-48

“But if anyone strikes you on the right cheek, turn the other one also.”

So let me begin by saying that as a therapist, as a clinical social worker/pastoral counselor, I do not like this passage much at all. In my time as a social worker, I have worked with all sorts of vulnerable people, from those who were homeless, to people who were dying, people addicted to substances and behaviors, to folks struggling with illnesses, physical, mental, or both. And so the worst part to me about this passage, is when you are working with people whose situation involves a bully, an abusive spouse or partner, or working through abuse that occurred as a child. Because most of us, when we hear this passage, we hear this: “Just let them take it and give them more.” “Turn the other cheek so that they can just hit you again.”

It is almost as if we hear this as “just be passive, a humble servant, and this is what God wants.”

And I strongly disagree with this interpretation. I am made profoundly uncomfortable in hearing these words as a reason for someone to remain in a situation where one is being hurt, where you are broken and afraid. But perhaps there is a different word here in this passage, a different layer of meaning, which we miss somehow.

After all, what should not surprise us, but does sometimes, is that Jesus speaks in different ways to different people. For the pharisees, who were so religiously pious in the temple that they did no good out in the world, Jesus says, “You brood of vipers!” And to those who were sick and vulnerable, Jesus doesn’t say that “I have made you whole,” but instead tells them “your faith has made you whole.” Jesus chases out the moneychangers in the temple, but when the disciples were shooing the children away, Jesus says, “Let the children come to me.”

We miss the message if we miss that Jesus was on the side of the vulnerable, the hurt, these that are called “sinners” at times. I first encountered this way of thinking in a class at Union Presbyterian Seminary in Richmond, a class called Contextual Theologies where we read articles by authors who were writing about their experience of God and scripture based on their particular experience, often an experience of being an outsider or powerless in some form or fashion. One article that we read was by a woman named Valerie Saiving. She argued that even our very idea of sin, of sin as pride, as being “too much,” that this is a particularly male way of looking at the situation. She writes that for most females, especially during the 1960s through 1980s when Saiving was writing and teaching, that sin for women could be not recognizing God’s image in them too. Sin was not standing up, that women instead should be encouraged, not discouraged. This is what we hear in Mary’s song, the Magnificat, about this savior who is coming that will raise up the meek, and will bring the mighty down.

And to me, that sounds like a fight, right? That sounds like getting your fists up and ready, guns blazing, time to take them on! Eye for an eye, right?! Tooth for a tooth, right?!

Oh, but wait a minute . . . we have this passage from Matthew. Jesus is telling us NOT to do what feels so natural. We have heard it said “an eye for an eye,” but Jesus tells us, as followers of Christ, that this is not who we are to be.

 So now what?!? Do we fight? Do we just give in? Or is there some other way?

And here is the struggle, in this challenging passage. Jesus does not talk to us in either/or dichotomies because that is not how God is. God is not either/or; God is both/and. God does love those who are vulnerable, rest assured. And we emphasize God’s special love for the vulnerable so that we, who may have more, we remember that just because some of us have more, it does not mean that God loves us more. God loves the weak and the hurt, but God loves those who are strong too. God loves the oppressed, but God also loves the oppressor . . . and loves them enough to not allow them to remain in a system, a system of sin, that hurts and oppresses, a system that kills them and their spirit too.

God loves all of us.

    And truth is some of us don’t like that very much.

Funny thing is even the old “eye for an eye” rule was an improvement. There was a time that when people were hurt, they hurt someone else. Then that person just hurts back, over and over, in a continuous cycle of vengeance. So stopping at one tooth for one tooth, in actuality that was an improvement over what had been. But then what takes this ethic even further, is what Matthew describes here. Jesus advises actions that do NOT retaliate, not committing another wrong because of the first wrong. Instead Jesus proscribes acts that point out injustice. These responses are ones that shame the one in power, that point to the wrong and stand with dignity in the face of that wrong.

So without getting too far into the mores of that age, the scene Matthew is describing is one where someone in power has hit someone with less power, with the back of their hand on their “right” cheek, a gesture intended not only to sting, but to humiliate the one who was hit. So what does Jesus do? Jesus tells the one who has been hit to turn the other cheek, forcing this person to hit them not with the back of their hand, but the front, which would make them an equal, not a hit as master to servant but between equals. This gesture, this turning of the cheek is a standing up, not cowering down.

And this business about the cloaks and coats, if you were sued to the point where you are standing in court and you have nothing left to take except your coat and cloak, then giving this person everything you have leaves you naked. You are standing there, standing in the court, in front of God and everyone, quite literally. But this nakedness, again according to the mores of that day and place, this would not be a shame on you, but a shame on the one who sued you. The shame is on the one who took everything, the one who has now left you with nothing. Again, this action is a pointing toward justice, pointing out injustice, not for the sake of committing one more wrong for the wrong done to you, but pointing to a higher right.

And it is fitting that we hear this passage during Black History Month in part because the civil rights movement in this country succeeded because of the way of non-violence. This was not a movement that was passive, but fought in a way that means the salvation not only of the oppressed, but the oppressor. This is not a God that wants anyone to remain in their sin, whether that is sin that hurts an individual, or the sorts of sins that hurt all of us, as racism did and does still. God is calling all of us home, the strong and the weak, the vulnerable and the powerful.

Because this is a God who wants us to love as God loves. This God loves us all. That is what this “perfection” that Matthew speaks of is like, a perfection, a heaven if you will, a beloved community where we all belong.

–St. Andrew’s Presbyterian Church, Macon, Georgia

The ABCs of Mental Health Treatment

[Note: This is the last in a three-part series of articles written several years ago for a local publication. The purpose was to do some education about mental health, especially for a church audience. I thought it might be good to revisit.]

LMFT.  LPC.  LCSW.  PsyD.  MD.  M.Div.  Ph.D.  CAC.  RN.  CSB.  Medicaid.  Medicare.  MHP.  When you dive into the bowl of alphabet soup that is our mental health system, it is confusing mix of letters, providers, payment types, and places to go for services.

How do I access the mental health system?

The first item to know is how to access the system in situations of dire need.  In other words if you or a loved one are unable to leave the house because of debilitating depression or anxiety or if you or a loved one is suicidal or homicidal, then you need to call emergency services at 911.

If the need is not an emergency, but is urgent, then it is a good idea to call your regular doctor or pediatrician and discuss the symptoms you are noticing and ask for a referral.  Many times the doctor may ask for a blood test to evaluate for other conditions that may look like depression or anxiety.  Thyroid problems or diabetes are common conditions that have symptoms that may look like mental health concerns.

Another important consideration in our health care system is how you are going to pay for services.  If you are insured, it is best to look at your insurance card for words such as “behavioral health” or “mental health” or “substance abuse” and to call the number on the card to discuss a referral.  Many insurances have separate plans for mental health coverage; it is important to understand these rules so that you do not go to a provider that is not “in-network” and then face a large bill.

If you are not insured, or are insured by Medicaid, another avenue for mental health services is your local community service board.  These are the state-funded mental health providers such as Oconee Center, Phoenix Center or River Edge Behavioral Health Center.  They typically have a variety of services ranging from all-day services for adults, treatment for addiction, counselors and psychiatrists.

Lastly, there is inpatient treatment.  While there was a time when inpatient treatment last for weeks and perhaps months, being hospitalized in a psychiatric unit typically lasts for three days to one week.  Treatment in this setting is to manage a temporary crisis until a patient can be stabilized and released to outpatient treatment.

What happens at a psychiatric hospital?

Inpatient units are typically in a large hospital or in a separate psychiatric facility.  Inpatient treatment is NOT what many of us saw in the film One Flew Over the Cuckoo’s Nest.  Typically, there are counselors, nurses, and psychiatrists on staff there who will monitor whether medications are working.  There are also groups and classes that patients attend to work on the life circumstances that may have created or may be maintaining some of the problems in their life.

There are also in-between sorts of options for people who need the intensity of everyday treatment, but are not needing to stay in a locked unit.  These programs are usually called “intensive outpatient” or “partial hospitalization” programs.  These can be wonderful options!

But who are the people who provide these services?

The type of provider you need to see is largely based on what type of need you have.  Just as doctors are regulated by a medical board, there are also boards that license and regulate counseling.  These boards ensure that providers who hold that license have fulfilled the requirements, both in terms of education and experience, which enable them to competently provide mental health counseling and psychology.

If you are looking for psychological testing, then a psychologist is who you need to call.  These tests (which are both paper/pencil and computer-based) can test for everything from mental illnesses, learning disabilities, intelligence, and can also be helpful in assessing career paths and in helping groups of people learn more about each other to help them work better together.

Some psychologists also provide therapy to help with behavioral health issues.  These are generally folks with a Psy.D., but may also be people who have a Ph.D.

Other providers typically have a Master’s degree in professional counseling, marriage and family therapy, or social work.  Master’s level providers are the bulk of people providing therapy to address behavioral health.  The type of license is either a LPC, LMFT or LCSW.  Sometimes you will see someone with a LAPC, LAMFT, or LMSW; this means that this person does not yet have their full license, but is working towards the ability to practice independently.

What happens in therapy?

Typical sessions with a therapist or counselor are 50 minutes and cover some of the patterns of behavior, family structures, and ways of thinking that may exacerbate the problem or have led to the problem.  The MOST important item in finding this type of provider is that you feel you have a good “fit” with this person.  Research has shown that beyond the style/type of counselor, whether you have a good fit with them is one of the strongest predictors that you will get better.

Meds?

Master’s level providers and psychologists do NOT prescribe medications.  Psychiatrists are the providers who do treat mental illness with medication and other interventions that require a license to practice medicine.

Another group of providers are certified addiction counselors.  These are people that have been through training and supervision in order to specialize in providing services for people struggling with addictions.  While this is not regulated by the state of Georgia, there is a state organization that certifies them.

In finding a provider, insurance is definitely a factor, but you should also ask your clergy, your friends, and your family about their experiences with a provider.  The “fit” is important, so make sure that you trust and are comfortable with the person.

Mental Illness in the Church

[Note: This is the second in a three-part series of articles written several years ago for a local publication. The purpose was to do some education about mental health, especially for a church audience. I thought it might be good to revisit.]

We bring food.  We knit prayer shawls.  We call or text or email or even Facebook and tell people that we are thinking about them and praying for them.

These are some ways in which our churches respond to people in need.  We signal to the people around us that we care, that we are available, that we hurt with them, and that we want to help if we can.

This is how we respond to deaths in families.  It is how we respond to heart attacks, surgeries, and all manner of scary physical illnesses.  The tough part is this: for many people, their faith community seems absent when the illness in question is not “physical.”

We understand heart disease.  We know lots of people that have had to have their gall bladder removed.  And even though many of us are aware that there are people in our churches who suffer from depression, addiction, schizophrenia, bipolar disorder, and anxiety, we do not tend to respond in the same way.

We don’t bring food.  We don’t knit prayer shawls.

Sometimes we don’t respond at all.

But we are called as people of faith to do more.

An important aspect of Jesus’s ministry was one of healing and of bringing people back into relationship with God and the people of God.  Jesus did this not with a spirit of fear, but a spirit of compassion for those who were hurting and vulnerable.

So when Jesus saw a leper, he reached out to touch them.  When Jesus saw someone who could not walk, Jesus healed them.  When Jesus saw the children, some of the most vulnerable members of that society, Jesus said, “Let them come to me.”  There was not fear in Christ’s response, only compassion.

But sometimes, especially with mental illnesses, there is fear.  Most of that fear is our lack of understanding.  Most of us have some understanding of illnesses such as depression or anxiety because we may have felt this way at some point.  It is more difficult to be unafraid when someone tells us that they or their loved one has schizophrenia or autism.

And then we hear Jesus’s voice saying to us, “Peace.  Be still.”  And even though we may not understand, we are called to react with compassion and caring.  And even though there is a part of us that wonders why such an illness would happen, we are called to be open to where God is working in our life and in the life of this person and family who is hurting.

We should not blame the person or the family.

Jesus tells his disciples as much in John 9 when the disciples ask, “Who sinned?” when confronted with a man who was blind from birth.  And Jesus responds, “Neither this man nor his parents.”  And then Jesus reorients us to acting with compassion, not judgment.

We should be compassionate to the whole family because like any other illness, a mental illness affects them too.  We can bring food (because they may be going back and forth to the hospital and have a tough time attending to household chores).  We can bring prayer shawls or flowers to let that person and their family know that we care.  We can pray for them, for peace, for comfort, and for healing.

And in our churches, we should be compassionate to folks with mental illnesses just as we would with any other illness.

What does become more difficult is that some illnesses, especially addictions, become very difficult for families to weather.  And I would argue that at times, family members must set strong boundaries with other family members about their need to be in treatment in order to protect themselves and their families.

Remember, mental illnesses express themselves in thoughts and behavior.  The ill person themselves may not be thinking clearly and may behave in ways that are uncharacteristic for them.  Many older adults with diseases like dementia have personality changes.

This does become an area where as supportive friends and church family, we must be careful with our own limits and boundaries.  For example, it is fine to express our care and love and God’s care and love for the person who is ill and for the struggle of their family.  But we need to be discerning about how or even if we need to intervene in some way.

Just because we believe that we may know the right action to take in a situation, does not mean that we do.  There are times when those of us on the outside may even disagree with a family’s decision, but disagreeing does not mean not showing care and concern.

Oftentimes without being inside of that family, we will not know the day-to-day struggles.  We will not know what has been tried and what would not suit this particular family.  But we can show God’s love for people who are hurting.

And finally, as leaders within the community of faith, whether clergy or lay leaders, we should have an idea of the local resources available to people with mental illnesses and addictive diseases and their families.  These referrals will ideally be people who are trusted and will provide good care to the people in our congregations.

Am I crazy or what?!?

[Note: This is the first in three-part series of articles written several years ago for a local publication. The purpose was to do some education about mental health, especially for a church audience. I thought it might be good to revisit.]

CRAZY!  Lunatic.  Maniac.  Nuts.

These words are easy for most of us to say.  We use them all the time to describe something that doesn’t “make sense”.  Or someone who is doing something that we don’t understand or with which we disagree.

What gets tougher is when we use the words “mental illness.”  And trying to tease out what we mean by those words, especially as people of faith, is a harder task.

Depression and Anxiety are not moral problems.

Maybe it is tough for us as Christians, because for a long time we have looked at illnesses such as depression or anxiety as moral problems.  We don’t look at the biochemical reasons why someone might be “down” or “worried.”  Sometimes we think or even say, “Well, they just don’t have enough faith.”

The tough part of that response is that is misses Jesus’s compassion for ALL people who are hurting and vulnerable.  And someone who cannot leave their home because of crippling panic attacks or someone who thinks about their own death nearly every hour of every day is hurting and vulnerable.

There are certainly times when we need to be reminded of God’s hope for all of us and times when we should remember that we have been asked by Jesus to “be anxious for nothing.”  Those times may reflect a struggle in our life, but that is different from a mental illness.

What is a mental illness?

Mental illnesses go by names like Panic Disorder, Schizophrenia, Major Depressive Disorder, and Bipolar Disorder.  And the line that gets crossed from “struggle” to illness is a line where the illness is causing serious problems in your life.

For example, someone who overeats may be having a struggle and may be experiencing some negative effects that come with being overweight, but that is very different from another person who begins to have diabetes or cardiovascular effects from the excess weight.  At some point, what may have started as a “condition” is now out of control and dramatically affecting that person’s life.

Many people experience a panic attack at some point in their life.  Panic attacks usually involve your heart racing, shallow breathing, feeling VERY scared, muscle tightness, shakiness, narrowing of vision, and quite often happen in a situation where you may be safe, but your body and your brain are giving off major danger signals.  Many people experience this!

But then what fewer people experience is when they begin to fear having the panic attack again.  This leads people to avoid situations where the attacks have occurred.  Then you begin to avoid activities that might lead to an attack.  And then you are afraid to even leave the house because home seems the only place that is safe.  That is Panic Disorder.

Illnesses needs treatment.

And when a condition rises to the level of an illness, most of us seek treatment by someone who specializes in that illness.  If you begin to have frequent urination, dry mouth, have extreme hunger, fatigue, irritability, frequent infections, blurred vision, and other symptoms, you would talk with your doctor about the possibility of diabetes.

It is not much different if for over two weeks you have difficulty making decisions, feel fatigued, guilty, hopeless.  If you have a change in your sleeping, either sleeping way too much or insomnia.  If you felt your appetite change and began to lose interest in activities that used to be fun.  And if you began having thoughts about your death or even suicide, then you would want to talk with someone who could help with your Depression.

And even though sometimes we may feel “crazy” when we our emotions and thinking are like these examples, we are not.  We have an illness.  And God’s response to people who are hurting and vulnerable is compassion.  And sometimes we need to have compassion on ourselves too and make effort to get the treatment that we need.

That doesn’t make you crazy.  It makes you smart.