Most people assume that when they need to see a therapist, their health insurance will help pay the bills. This is only true in part. Most health insurance providers have relatively strict guidelines about what “conditions” are covered. Health insurance after all helps to pay medical bills for health problems. The factor that most determines if insurance will cover therapy is the diagnosis. If you are being treated for a mental illness, insurance will usually help. There are several problems therapist routinely help clients with that do warrant counseling, but do not get diagnosed as mental illness. The end all be all of clinical diagnosis is a book called the DSM-IV (Diagnostics and Statistical Manual version 4). Nearly all of the reasons a person might see a mental health professional are discussed and “coded” for the sake of insurance billing and record keeping. Among the various reasons for seeking professional help are a category of diagnoses called “The V Codes”. V code diagnoses are not considered mental illnesses and are seldom covered by any insurance policy. The most common V code that people are surprised to find themselves not covered for by their insurance is marital/couples counseling. Fighting with your spouse or significant other (partner relational problem) is not a mental illness and very few insurance providers are willing to pay for you and your partner’s inability to get a long. Another V code diagnosis clinician’s see often is bereavement. When a person has experienced a profound loss in their life, like a loved one passing away, counseling can be an excellent source of support. Again, being upset after a profound loss is quite normal and as such is not considered mental illness. The third most common is what is generically called a “phase of life problem”. Phase of life problems include all kinds of things that people can have a hard time coping with that are the challenging parts of life we all experience. It includes things like changing jobs, getting divorced, being a better parent, reacclimating to being single, issues of ageing and dealing with financial hardship. Like all the other V codes, people often seek a therapist with good reason for these problems, but they do not rise to the level of mental illness. Other common V codes which therapists see clients for are parent and child relationship / interaction problems, religious / spiritual difficulties, occupational problems, academic problems and acculturation problems that arise from people experiencing alienation in an unfamiliar culture. Many of these problems in very extreme situations can persist long enough and have such dramatic symptoms such as to rise to the level of mental illness, but fortunately that is uncommon. Some therapists are eager to exaggerate the seriousness of a client’s problem such that they can diagnosed them as a mental illness rather than a V code and qualify the client for insurance benefits. Not only is this unethical but it is fraud; motivated by a clinician’s desire to help a client get assistance they may be otherwise unable to afford.

Most therapists are quite proficient in their profession and can help practically every client they work with. Just because all therapists share the same fundamental skills, this does not mean that all therapists are the same or that all therapists and clients are guaranteed to be a good match for each other. Most of the time, it is the client who chooses which therapist they will be working with. A prospective client has the right to shop around for a clinician that they think will best suit their needs. When a client decides that it is time to see a counselor, it’s tempting to just look on the internet or in the phone book and choose the one they find who is closest to home or cheapest. Though cost and location are clearly considerations, other things are important too. Therapy is a substantial investment in time, money and interpersonal commitment. Don’t feel compelled to latch onto the first therapist you find. It’s unfortunate but true that the same difficulties that compel a person to seek a therapist in the first place are those that can make even looking for one a challenge. Even making the first telephone call to a therapist is a huge step for many facing mental illness. It can feel intimidating to some. Often when clients do make a first call, they want to get it over and done with as soon as possible. Most people are reluctant to try new things and procrastinate. Looking for a therapist is even harder because it involves telling a stranger some of your most embarrassing difficulties and admitting you have problems with things “normal people” seem to handle just fine. Something good you can tell yourself when you are looking for help is that…You are a customer and therapists want to offer you their services. Remind yourself that a therapist is not there to judge, intimidate or make you feel inferior. They are there to help you. They are competing for your business. If you have ever had the misfortune of trying to get yourself an appointment squeezed into a medical doctor’s busy schedule, you will be pleasantly surprised to find that most therapists will have plenty of availability. With medical doctors, supply and demand often works in the doctor’s favor because there are so few doctors and so many that need their help. In mental health, the supply and demand equation works more in the favor of the client. As a prospective client, you are hiring somebody who wants to work for you; don’t be afraid to interview them a bit. Don’t be afraid to interview several and pick your favorite. In a true therapeutic relationship neither the therapist nor the client has power over the other; both work cooperatively for the benefit of the client. This is collaboration. Choose a therapist as a partner who you think you can have a cooperative and collaborative relationship with. Perhaps the first thing you should look for in a therapist is their personality. In most places there are plenty of therapists who have ample experience working with most common problems. Looking for one that you seem to feel a good rapport with can be a better start than considering their various licenses, degrees, schools and stated specialties. If you have particularly strong religious, political or cultural beliefs, don’t be afraid to ask a potential therapist about things that are important to you. Don’t be afraid to ask a therapist about what types of clients they seem to have the best experiences with. Even though therapists are trained to work effectively with people from very diverse backgrounds, they do have some types of people they just relate to better. Don’t be afraid to ask about past times or personal interests. Many times a client can feel much better understood by his therapist when he knows that therapist has had some similar experiences. More and more, psychotherapy is becoming a niche industry with various therapists catering to specific types of clientel. Why sell yourself short and work with the therapist down the street when there very well could be a clinician who better suits you in the next town?

Psychiatrist- A psychiatrist is a medical doctor who’s specialty is treating mental illness by means of modern medicine. Psychiatrists primarily treat mental illness by prescribing medication. Continued contact with a psychiatrist who prescribes medication is important so that they can monitor the benefits and side effects of those medications and decide if the results are good or if changes need to be made. In many ways, prescribing psychiatric medication is an art, and a good psychiatrist may have to try several different medications in different dosages to find what works best. Because they are medical doctors, they often use other medical techniques in their assessment and treatment of mental illness. Electroencephalography, CAT Scans, and MRIs are occasionally used. In some extreme cases even Electroconvulsive therapy is an option for psychiatrists. Psychiatrists rarely involve themselves in providing talking therapy. It is very common for other mental health professionals to refer clients to a psychiatrist when there appears to be need for psychiatric medication.

Psychologist- Generally speaking, Psychologists have a Ph.D. in the academic field of psychology (as opposed to psychiatrists who have medical degrees). Psychologists have a lot of flexibility in how they practice. Many serve as professors at universities and colleges. Aside from teaching, they also conduct psychological research and write academic papers. Psychologists are also very good at utilizing a wide variety of psychological tests. In many ways, practicing psychologists specialize in diagnostics and client’s who are particularly challenging. Many psychologists do talking therapy and are generally quite well trained in it. As a rule, psychologists do not prescribe medication because they are not medical doctors. It’s common for other mental health professionals to refer a client to a psychologist for psychological testing when there seems to be a need. Many places in the US are flirting with the idea of licensing psychologists to be able to prescribe a limited range of medications themselves.

The Psy.D.- A Psy.D. is really just another kind of Psychologist. It is an academic doctoral degree like a PhD which places less emphasis on research and more on clinical practice. Clinicians with a Psy.D are generally very skilled in talking therapy as well as psychological testing. A Psy.D. is a pretty good choice for any client that is in need of seeing a “Psychologist”; but a poor choice as a research associate.

Psychotherapist- A psychotherapist specializes in talking therapy. They do not prescribe medications and use few psychological tests. Most of the leg work in mental health is done by therapists. Generally speaking, a therapist talks to his clients and uses his specialized insights to help clients better understand things about themselves and the world around them. Therapists can help people with most mental illnesses as well interpersonal relation problems and difficult life transitions. Therapists specialize in helping clients feel more empowered and encouraged. They help client’s sort out how they think and feel about things. They gently challenge people when their thoughts and feelings are inconsistent or don’t fit reality. Ultimately therapists help clients to make better choices and think about things in a more appropriate manner.

Counselor- Counselor is a very generic term. It is often used interchangeably with psychotherapist. In some places anybody can call themselves a counselor. In other places there are licenses for several different types of counselor such as mental health counselor, pastoral counselor, vocational counselor, school counselor, substance abuse counselor, domestic violence counselor, and credit counselor. There are some places where “counselor” can refer to anybody who works with people on various problems by talking with them. In some places “counselors” can work with people who are having life problems like divorce, marital conflict and grieving, but can not work with people suffering mental illness or addiction. Ultimately this term can vary greatly based on the applicable local laws.

Social Worker- Social Workers are a remarkably diverse group. They work in schools, prisons, social service agencies, advocacy groups, hospitals, government bureaucracies, retirement communities, etc. Fundamentally, social workers are there to help other people. This can be one on one service helping a client locate community resources they need or even world wide activism promoting various ideas about “social justice”. In most places, social workers can be licensed and practice talking therapy like a psychotherapist. Though some are clearly qualified to help clients with life problems and even mental illness, that is not the specific specialty of all social workers.

Neurologist- Neurologists are medical doctors who specialize in treating problems with the central nervous system. People most often see neurologists when they have brain and spinal damage or malady. In the realm of mental health, professionals will refer to a neurologist when they think mental health problems are the result of a client having serious organic problems with their brains. Such problems generally come from head trauma, developmental disabilities or substance abuse problems. Viral infections, strokes tumors and plaque build up are also common organic brain problems that can produce emotional, cognitive and behavioral problems. Like any doctor, neurologists address medical problems with surgeries, medications and other medical treatments. Neurologists rely heavily on Electroencephalography, CAT Scans, MRIs and other ways to examine the physical brain. Mental health professionals will often refer to a neurologist when particular symptoms that suggest brain damage are present. A referral to a neurologist is often done “just to be sure” the client is not in medical danger and to “rule out” serious organic problems as the source of mental health problems.

Psychoanalyst- A psychoanalyst is much like a psychologist or psychotherapist that specializes in psychoanalysis. Psychoanalysis is style of talking therapy that is somewhat controversial. It was the talking therapy that started it all back with Freud. Since that time, most other mental health clinicians have evolved new talking therapy treatment approaches, but psychoanalysis continues on only somewhat altered. Where as most talking therapy today focus on helping clients process and grow in the present, psychoanalysis deeply examines a client’s past and tries to resolve hang-ups from formative periods in a person’s life. Unlike more modern psychotherapy approaches which seek efficient improvement for their client’s, psychoanalysis often occurs several times a week for 5-7 years.

Ironically, one of the things that most keeps people awake at night is worrying about being able to get to sleep in time and get enough sleep that night. I can’t tell you how many times even I myself have fallen prey to this irrationally self-destructive mind set. What then are we to do? First we have to fully accept the realization that all the worry we are going through is not really helping us but is more than likely making our situation worse, depriving ourselves of rest. It’s also beneficial to realize that we are likely not going to cure cancer or solve world hunger laying in our bed thinking about it. We have to learn the difference between good contemplative problem solving and wasteful worry. We need to understand that we will be better off facing our problems for real in the morning with a well-rested brain.

Some people have told me that they benefit from a vigorous work out in the late evening. They tell me that the exhaustion they have from exercise helps them get to sleep faster. Others have told me that exercise late in the evening fills their body with adrenalin and endorphins that keep them from getting to sleep. I suspect that these both may be true and that different people have different experiences. Don’t be afraid to experiment a bit with your personal sleep regiment. Perhaps you may want to try working out before bed for one week and doing something very relaxing like a long hot bath another week. Compare and contrast which, if any, changes seem to help or hinder your sleep.

Don’t be afraid to try a sleep mask or earplugs if light or noise keep you up. Light and noise might even be a factor you have over looked because they are so normal and uncontrollable. Some people fear that these masks and plugs make them look silly. Hopefully your partner won’t give you too hard of a time. Other people worry that they will not be able to hear their alarm clock or a fire alarm. Generally these sleep aids don’t limit perception that completely. Try them out on a weekend when it’s not critical that the alarm wake you

Tossing and turning will keep you up all night long if you let it. When we are uncomfortable, it’s natural to flop around seeking for a better feeling position. When you find yourself unable to get comfortable, make drastic changes sooner than later. Don’t waste an hour fluffing your pillow when you could have gotten another one from the closet. If you feel too hot or too cold, change what you’re wearing or adjust your home’s climate controls early on. When you run out of options for improving your situation, stop. If you are going to end up uncomfortable in any position, resign yourself to being uncomfortable and try to shut out the physical experience in favor of the mental. It is possible to sleep in physical discomfort. Throughout history, people have slept on dirt floors, sitting in chairs and even in rain filled battlefield trenches. Remind yourself that the creature comforts are nice, but you can make the best of even the worst mattress and pillow. Settle in for the long haul and lay still.

What we consume before we go to bed is important. Be mindful not to eat and drink things that are going to necessitate going to the bathroom or which will give you heartburn. Choose only foods that sit well with you and won’t upset your stomach. By all means, avoid sugar and caffeine. Foods that are known to contain the chemical tryptophan have long been thought to induce drowsiness. More recent studies seem to dispute this. Rather, large heavy meals rich in carbohydrates are the true source of Thanksgiving drowsiness. Though a rich heavy meal may induce drowsiness, it’s not a healthy prescription for a bit of sleep. Warm milk is another home remedy that has pretty much been debunked. Perhaps it does still have value as placebo. If you really believe that turkey sandwich and glass of milk will help you get some Zs, they just might.

Stretching a bit when first lying in bed can help a great deal. I’m not talking about the kind of stretching we do before a work out, but more of the stretching you see a cat do where they extend their arms and legs and arch their backs. This stretching relaxes the body as a whole as well as loosening us up so that our sleeping position will feel more comfortable

Last but not least, yawn. Yawning has a surprisingly beneficial effect on the human body in terms of preparing for sleep. It’s natural for many people to attempt to cut their yawns short. If you need help getting to sleep, let your yawns last for as long as comes naturally. There is a strange psychological and somatic aspect of yawning which people say is “contagious”. Watching other people yawn has been proven in the research to induce yawning. Even thinking about yarning or visualizing others yawning can make you yawn. Even faking a yawn can often produce a real yawn.

One of the most common problems the average person experiences in life is a lack of sleep. Fortunately, recent studies indicate that more Americans have been getting much more adequate sleep over the past couple of years. Recent studies say that the current average is 48 hours a week. Hopefully this trend or better rest will continue.

The factor that most keeps people awake at night when lying in bed is that they are simply not “sleepy yet”. Not feeling ready to fall asleep at night is generally a good sign of being adequately rested. This is the biggest problem when an abnormality in a person’s schedule makes a person “have to go to sleep” at a time when they simply aren’t tired enough to do so. It’s very hard to go to sleep at 8 pm to wake up at 4 am when your body is accustomed to going to bed at 11 pm to wake at 7 am. There is a good chance you will simply sit in bed waiting to sleep until 11 pm anyhow and getting only 5 hours of sleep. Over the counter sleep aids are a great way to prepare for nights when our lives demand that we sleep when our bodies are not really ready. As always, it’s best to fully understand the medication warnings and consult with a doctor if you have any concerns or complicating factors.

The next greatest challenge to getting to sleep is active thought. Some people will say it’s anxiety and worry. They are not completely wrong; I am simply identifying a more basic root cause. Many people who lay awake at night do so because they are ruminating about something. Our brain does not do well in drifting off to sleep when we are engaging it in directed active cognitive processing. Not all thoughts that prevent sleep are negative thoughts. Enjoyable, happy thoughts can keep you awake as well. It’s not the specific content of the thoughts; it’s the active use of the brain that keeps it awake. People lay in bed worrying about money and relationships. People stay awake at night trying to figure a way out of this problem or that. People also stay awake at night musing over fun and interesting events of the day. They ponder how they should best spend vacation time or a bonus. Some even consider the odds of their favorite sports team taking home a championship this season. In addition to active thought keeping the mind in an alert state, many thoughts induce emotions that perpetuate additional dwelling on our interpersonal experience, which is not conducive to sleep. Emotional experiences trigger the release of endorphins that can energize or agitate us and prohibit us from drifting off to sleep. The secret to a good night sleep is letting the mind and it’s thoughts drift out of conscious control. Remember back in school when your teacher was talking, but you were staring off into space daydreaming? That very way of letting you mind drift off in what every way the subconscious chooses to take it is one of the best ways to begin getting to sleep sooner and getting more before the alarm clock goes off.

(More tips to follow in my next article.)

When I work with people who suffer from poor self esteem, many more times than not they tell me about a childhood in which they were criticized or sheltered. When studying how self-esteem develops, I looked first at my own personal early life experiences. I was not in sports but I was in Boy Scouts and I consider it one of the most formative of my life experiences. As a Boy Scout, I did dozens of things as a child that otherwise I would not have done. My troop was very active. I went camping, fishing, rafting and canoeing. We built fires and bridges. We hiked long distances in awful weather and we navigated ourselves safely home when lost. Back in those days we fired rifles and shot arrows with bows. We used knives and axes as essential tools and our leaders demanded responsible handling of these dangerous items that we were entrusted with. I swam a mile across a lake in summer camp. I was taught first aid and CPR in case somebody got hurt. I learned to sail boat and ski. Most of all, I learned that I could learn. After Boy Scouts I had a very “can do” attitude about many challenges in my life. Boy Scouts lacked the competitive element of sports that most other boys had, but it certainly confirmed my ability to confront and overcome obstacles. When you become accustomed to overcoming challenges, it’s easier to take on new ones. When you assume you can take on the next challenge and figure out the next problem, you generally have the confidence to do so. When I look at my childhood belongings, I don’t have a lot of trophies. The few I do have I can’t remember fully what they were for. What I do have however is a mental repertoire of things I had done as a child that taught me that I was capable of taking on the world. Many times, simply the experience of having “been there and done that” is better than all the therapy, coaching and trophies in the world. In my own clinical work I try hard to encourage my clients who have anxiety and self-esteem problems to try new things. Even small things at first that have no relation to the specific thing a client has anxiety or a poor self concept about can give a client a sense of general accomplishment and adventure which bolters self esteem. This shouldn’t be limited to people who have a “problem” with self esteem or anxiety. Every person’s confidence and self-image could likely benefit from experiencing a few new things in their life from time to time. You don’t have to climb Mt. Kilimanjaro. It could be something as simple as a walk through an unfamiliar forest preserve or trying a new type of food. Each day our lives present us with the option to do the same old thing or to try something different. We don’t generally have to try that hard. Often opportunities to experience new things are handed to us on a silver platter and all we need to do is welcome them. Keep a look out for the next new experience opportunity that comes your way and take it.     

When people talk about mood disorders, Major Depression and Bipolar Disorder seem to get all the press. There is another mood disorder that often goes undiagnosed, untreated and even misdiagnosed. What I’m talking about is called Dysthymia. It’s a form of depression that is not quite as intense and lasts a very long time; at least two years. Many people suffer from it for their entire adult lifetimes. Many people who have Dysthymic Disorder do not think of themselves as seriously depressed, but rather as “frequently sad”. Research suggests that at any given time, nearly 3% of Americans actively suffer from Dysthymia. Many who experience Dysthymic Disorder suffer just a bit too little to seek help and instead suffer in silence. When Dysthymic clients do seek help, the symptoms are often interpreted and diagnosed as Major Depression instead. Because of misdiagnosis and people failing to seek help for Dysthymic disorder, that 3% prevalence figure I mentioned earlier may be much higher. The most common symptoms of Dysthymia are feeling of low self-esteem and low self worth. A very pessimistic outlook and feelings of hopelessness are also common. Like other mood disorders, a lack of energy and motivation along with sleep and appetite changes are common. Dysthymia is best characterized by a person who is “moody” and more days than not thinks badly of themselves, bemoans his or her life circumstance, feels undeserving of happiness and generally resigns themselves to “just being down all the time”.

There is an even less talked about mood disorder then Dysthymia. It’s called Cyclothymia. Much like Dysthymia is a lighter and longer duration version of Major Depression, Cyclothymia is a lighter and longer duration version of Bipolar disorder. People who suffer from Cyclothymia have the same long term down in the dumps experiences as a person suffering Dysthymia, but also have occasional “hypomanic” episodes. These episodes are generally enjoyable and the person experiences an elevated mood, unusual self confidence, drastic reductions of worry, fear or anxiety, grandiosity, flights of ideas, rushing thoughts and a boost in creativity. People experiencing a hypomanic episode and people witrnessing one often think of this period in a very positive way. Some who are diagnosed as cyclothymic are hesant to treat it because they do not want to be deprived of the hypomanic episodes that make them feel larger than life and super capable. Some speculate that many of histories most notable artists may have been cyclothymic, doing their greatest works during hypomanic episodes.

For any of you who think you may have either of these two problems, there is help out there for you. Contact a mental health profesional of your choice. Like Major Depression and Bipolar Disorder, both Cyclothymia and Dysthymia can be treated with psychotherapy and medications. Don’t be one of those who suffer in silence a little bit day by day. Help is out there in a myriad of forms.

During my training, Dr. Lewandowski impressed upon me the understanding that the hardest of all behaviors to change was avoidance. Avoidance, he said, was self-reinforcing and it worked every time it was implemented successfully. Simply put, people who avoid things they dislike are rewarded by not having to endure the thing they are avoiding each and every time they successfully avoid it. Simple really. When things work, we continue to do them. Dr. Lewandowski also had a background in the gambling industry and frequently said that the most addictive things are those with an irregular and unpredictable reinforcement schedule. Like a slot machine, we find things most compelling when we are unsure which time we will get the pay out and which times we won’t. I never managed to reconcile these two beliefs against each other. What I have learned through experience is that he was correct about avoidance. Avoidance is a very hard behavior to treat because it has successfully served the client’s most fundamental survival instincts in the past. It’s hard to challenge a client to confront things that they find threatening when avoidance has kept them so safe in the past. An important step is to help the client begin to be less frightened of whatever it is they are avoiding. You also work to help the client better see and understand the consequences and harm that has been done to them through avoidance. Avoidance is a primary symptom in anxiety disorders, but most certainly exists to one degree or other among most every day people. Unlike so many symptoms we treat successfully today with medications, avoidance is best helped with psychotherapy. There is no pill to take this one on; you have to personally step up to the plate. A good therapist can be just the resource you need to assist and encourage you.