Making Sushi

Before you go into psychotherapy, you should be informed of your rights as a patient ahead of time by the therapist. The therapist should, in addition, give you a printed copy of something that reads similar to the below, so that you can take it home with you. We’ve long had a version of these rights here on our website, but I thought it might be helpful to further describe or explain each right in a little more detail.

Therapists nowadays may also often offer you their guidelines for electronic and/or outside contact, (such as through Facebook, email, telephone, etc). This sets the ground rules for how you may contact the therapist outside of session, in event of an emergency, or in the event that you just want to share something with your therapist (or change your appointment or such).

You should know that these rights are not absolutes, and there may be exceptions based upon what kind of treatment you’re undertaking, under what conditions, and in what country or province you live in (even state laws vary that may alter some of these rights). If you have a specific concern with one of these rights, you should discuss it with your therapist during your next session.

Every patient engaging in psychotherapy with a professional has the following rights:

You have a right to participate in developing an individual plan of treatment. Every client in psychotherapy should have a treatment plan that describes general goals of therapy, and specific objectives the client will work on in order to achieve their goals. Without such a plan, how would you know you’ve made progress?

You have a right to receive an explanation of services in accordance with the treatment plan. The therapist should describe the process of how they work with clients, in as much detail as you prefer and time allows.

You have a right to participate voluntarily in and to consent to treatment. You are there voluntarily and should understand and consent to all treatment provided you (unless you have been court-ordered or have other state-imposed restrictions).

You have a right to object to, or terminate, treatment. Don’t like therapy or a specific type of treatment? You can leave at any time without any kind of repercussions (unless you have been court-ordered to attend therapy).

You have a right to have access to one’s records. Yes, although many professionals don’t like it, you have a right to review the records they keep on you.

You have a right to receive clinically appropriate care and treatment that is suited to their needs and skillfully, safely, and humanely administered with full respect for their dignity and personal integrity. Your therapist should be skilled and trained to administer the treatment he or she said they would, and do so in a dignified and humane manner. You should never feel unsafe in your therapist’s presence.

You have a right to be treated in a manner which is ethical and free from abuse, discrimination, mistreatment, and/or exploitation. Therapists shouldn’t use your story to write a book, a screenplay, a movie, or have you appear on a television show. They shouldn’t attempt to leverage the therapeutic relationship in an inappropriate manner (e.g., sexually or romantically), and they shouldn’t pass judgment upon you based upon your background, race, handicaps, etc.

You have a right to be treated by staff who are sensitive to one’s cultural background. No matter what your background or culture, you should expect to be treated with respect and dignity, by all staff (including billing staff, receptionists, etc.).

You have a right to be afforded privacy. Your sessions are confidential and private and will not be overheard or shared with others.

You have a right to be free to report grievances regarding services or staff to a supervisor. More of an issue if you’re being seen in a clinic or hospital.

You have a right to be informed of expected results of all therapies prescribed, including their possible adverse effects (e.g., medications). Psychiatrists should go through the list of common adverse and side effects of any medication they prescribe. If a type of psychotherapy treatment also has adverse events, those should be described to you at the onset of treatment.

You have a right to request a change in therapist. Sometimes it just doesn’t work out with the therapist chosen. That’s nobody’s fault and the therapist should help you find his or her replacement (through a referral, at minimum).

You have a right to request that another clinician review the individual treatment plan for a second opinion. You are entitled to a second opinion by a professional of your choosing at any time.

You have a right to have records protected by confidentiality and not be revealed to anyone without my written authorization.

Carlo Mueres is a excellent depression therapist who have been working with depression for seven years. If you want more his help please check his depression and anxiety guide!

Skimming through Real Simple magazine at the check out line of the supermarket, I came across Dr. Robert Leahy’s “10 Ways to Cope with Anxiety.” Dr. Leahy is the director of the American Institute for Cognitive Therapy and the author of many books on the subject. His suggestions will help you calm your nerves:

1) Repeat your worry until you’re bored silly.

“take the troublesome thought that’s nagging at you and say it over and over, silently, slowly, for 20 minutes. It’s hard to keep your mind on a worry if you repeat it that many times.”

Dr. Leahy calls this technique “the boredom cure. “Behavioral scientists call it ‘flooding’. I’m not so keen about this technique for my extremely anxious patients who are having trouble regulating their thoughts and emotions. If your anxiety is on the milder side, however, and you have the courage to do this, I recommend you think about your worries while practicing relaxation techniques to keep your body as calm as possible.

2) Make it worse.

“When you try too hard to control your anxieties, you only heighten them. Instead exaggerate them and see what happens.”

This is a good one. When I suggest it to my patients I call it the ‘Bring it on’ technique or ‘Fake it ’til you make it’. By inviting what scares you, you learn on your time that you can survive your fears instead of waiting to be bushwhacked by them.

Sports psychologists use this all the time. When I was terrified my horse would shy and dump me on the ground, my coach told me to stop trying to keep my mare from bolting. Instead she told me expect her to shy, to look forward to it. That attitude helped me relax and so did the horse.

3) Don’t fight the craziness.

“You mayhave thoughts that lead you to think you’ll do something terribleor that you’re going insane Remember – our minds are creativeevery now and then ‘crazy’ thoughts jump out. Everyone has them.”

In the weeks after my first child was born, when I was exhausted, sleep deprived and in the grips of baby blues, I had thoughts of throwing my screaming baby out the window. Those thoughts terrified me. Tearfully, I confessed my horrible thoughts to my mother who shrugged and said, “We all think something like that at some time. You didn’t act on it, did you?” She assured me I wasn’t crazy. I could relax.

My patients are sometimes surprised when I suggest they allow themselves to imagine doing something outrageous like throwing a banana cream pie at their nasty boss’s puss. Unleashing our creative minds may be just what we need to de-stress.

4) Recognize false alarms.

“Many thoughts and sensations that we interpret as cues for concern-even panic-are just background noise. Think of each of them [rapid heart beat, tensing of muscles] as a fire engine going to another place.”

5) Turn your anxiety into a movie.

“..imagine that your anxious thoughts are a show while you sit in the audience, eating popcorn, a calm observer.”

This is a good way to exercise ‘detachment,’ stepping outside of the anxiety just enough to keep your thinking brain working. Another technique I suggest is to imagine the worry happening to a friend, not you. Then imagine talking to your friend. What would you say to them? How can you be supportive?

6) Set aside worry time.

“Try setting aside 20 minutes everyday-let’s say 4:30 PM-just for your worries. If you are fretting at 10 AM, jot down the reason and resolve to think about it later. By the time 4:30 comes around, many of your troubles won’t even matter anymore.”

7) Take your hand off the horn.

“When you desperately try to take command of things that can’t be controlled, you’re more like the swimmer who panics and slaps the water screaming Instead, imagine that you are floating along on the water with your arms spread outIt’s a paradox, but when you surrender to the moment, you actually feel far more in control.”

Breathe it out.

“Focusing on breathing is a common but effective technique for calming the nerves.”

This a classic, oldy, but goody. If you do it right, deep, mindful breathing is better than Valium.

9) Make peace with time.

“Every feeling of panic comes to an end, every concern eventually wears itself out, every so-called emergency seems to evaporate.”

When we are in the midst of a panic attack we feel it will last forever or else we will die. Remembering the fact that panic attacks and anxiety in milder form is finite, usually not lasting more than ten minutes. Dr. Leahy also counsels:

“Ask yourself, ‘How will I feel about this in a week or a month?’ This one, too, really will pass.”

10) Don’t let your worries stop you from living your life.

“What can you still do even if you feel anxious? Almost anything.”

Not all anxiety is bad. Keep in mind that some highly productive people transform their anxiety into motivation to do better and achieve much, both great and small.

Carlo Mueres is a excellent depression therapist who have been working with depression for seven years. If you want more his help please check his depression and anxiety guide!

All antidepressants may not be created equal when it comes to worsening of suicidal ideation during treatment, researchers found.

Men taking nortriptyline (Aventyl, Pamelor) were 2.4 times more likely to have an increase in suicidal thoughts than were those taking escitalopram (Lexapro), Nader Perroud, MD, of King’s College London, and colleagues reported online in BMC Medicine.

Nortriptyline, a tricyclic antidepressant, was also associated with a 9.8-fold higher risk of new onset of suicidal ideation compared with the selective serotonin reuptake inhibitor (SSRI) in the prospective open-label trial.

The reason behind the difference may be that nortriptyline acts predominantly on the noradrenergic system, which, when overactive, is associated with anxiety and agitation.

Because “suicidal ideation is more common in agitated and irritable types of depression,” the researchers said, “it is possible that nortriptyline may induce or worsen suicidal thoughts in some male subjects possibly through an induction of this more agitated type of depression.”

Another possibility is that nortriptyline is less effective against mood symptoms, they noted.

All antidepressants now carry black box warnings of suicidality risk, particularly in children and young adults, and especially early in treatment, but whether this risk differs between agents or by gender has been debated.

Prior studies have looked only at emergence of suicidal thoughts in patients who reported none initially, which “highlights the relatively rare cases with de novo treatment-emergent suicidal ideation,” Perroud’s group said, but could be “‘throwing the baby out with the bath water’ through removing a large proportion of patients at risk.”

So they analyzed findings from the Genome-Based Therapeutic Drugs for Depression (GENDEP) trial, “the largest comparative study of an SSRI and tricyclic antidepressant,” to look at both issues.

The multicenter study included 811 adults with moderate to severe unipolar depression allocated to open-label, flexible dose escitalopram or nortriptyline for 12 weeks. Among them, 473 reported suicidal ideation at baseline.

Overall, suicidal ideation dropped significantly over time in both treatment groups (P less than 0.0001).

And although nortriptyline was associated with higher mean suicidal scores than escitalopram throughout treatment (P less than 0.0001), the difference disappeared after adjusting for baseline scores (P=0.449).

Increases in suicidal ideation – defined as 0.5 standard deviation or greater score increase – were seen at some point in 31.9% of patients.

Treatment group did not appear to have an impact on suicidal ideation changes during therapy in the overall cohort, but it did make a difference in men.

Among men, the overall rate of increase in suicidal thoughts was 35.29% with nortriptyline compared with 23.7% with escitalopram. Even after adjustment for depression severity at baseline and during the study, the effect remained significant.

Carlo Mueres is a talented depression therapist who have been working with depression for seven years. If you want more his help please check his depression and anxiety guide!

Part of the problem in finding drugs which may be effective for dementia is that our ideas about what constitutes dementia have been undergoing radical change in recent years. It had been traditional to distinguish between Alzheimer’s dementia, or senile dementia of the Alzheimer’s type (SDAT) and multi-infarct dementia (MID), which is theoretically caused by small strokes which insidiously pick off brain tissue to the point where an individual’s cognitive function is compromised.

It was originally thought that MID accounted for 60%+ of the dementias. Accordingly, early attempts to treat the dementias concentrated on the multi-infarct dementias. The initial hypothesis was that these multiple small strokes were being caused by a process of hardening of the arteries, sometimes called arteriosclerosis and sometimes atherosclerosis (although these terms refer to two quite different disorders) which impaired blood supply to the brain. The logical treatment, therefore, for this condition was to attempt to dilate blood vessels. This led to the use of a wide number of vasodilating drugs such as hydralazine.

It is quite rare now for such drugs to be used for this purpose. Arguably, if anything, such treatment may have made the condition somewhat worse in that a potential effect of vasodilators is the reduction of blood pressure and reducing blood pressure would mean that the brain would be less perfused with blood, as one of the functions of blood pressure in the first instance is to provide the propulsive force to send blood up against the force of gravity to perfuse the brain.

Stage 2

More recent attempts to treat the dementias have proceeded on the basis that Alzheimer’s dementia is the commonest form of dementia. For many years, the term Alzheimer’s dementia was reserved for dementias that came on before the age of 65 (for this reason it was also called persenile dementia), which were not obviously caused by strokes. It was conceded that there was another dementia that was like Alzheimer’s dementia, which appeared to come on after the age of 65 but this was thought to be less common. Distinctions on the basis of age have now collapsed and both dementias of the Alzheimer type are now called senile dementia of the Alzheimer type. The amalgamation of these two groups led to an awareness that Alzheimer’s-type dementia is the commonest form. The primary therapeutic focus in the field, therefore, has been on an attempt to reverse the deficits which are supposed to be present in SDAT.

In particular, it has been held that in Alzheimer’s, there is a dysfunction of cholinergic pathways in the brain, for which there are both historical and clinical reason. Historically, when early work in psychopharmacology began, there were only four known neurotransmitters – noradrenaline, 5-HT, dopamine and acetylcholine (ACh). Noradrenaline quickly became the neurotransmitter involved in depression and mood disorders. Dopamine was known to be involved in Parkinson’s disease, and, when it became clear that neuroleptics acted on it, schizophrenia, after which the psychoses in general came to be seen as disorders of dopamine neurotransmission. For the most part, 5-HT was associated with either depression or anxiety. This left ACh without a function. It seemed convenient to parcel it out to the dementias.

There was, in addition, some clinical evidence in favour of an association between the cholinergic system and dementia. Part of the reason for this claim can be seen in a number of the chapters of this blog, in which drugs with anticholinergic effects have been noted as potentially causing amnesia or confusion (see The Management of Side Effects & Side Effects of Antidepressants articles).

Stage 3

In the last 5 years, a number of other dementias have been described. A distinction has been drawn between cortical and subcortical dementias. The cortex of the brain is the area responsible for higher cognitive functions, such as speaking, reading, planning and executing actions, etc In the cortical dementias, memory is usually the function most noticeably affected but those who are affected also have problems with planning even simple functions such as dressing and they typically cannot read, draw or execute any complex tasks. Alzheimer’s and MID are cortical dementias. There are also subcortical parts to the brain which are common to humans and other mammals. They involve a number of what are termed midbrain and brainstem structures.

Carlo Mueres is a talented depression therapist who have been working with depression for seven years. If you want more his help please check his depression and anxiety guide!