MY APPROACHES TO TREATMENT

I provide psychotherapy, psychoanalysis, psychopharmacology treatments for patients who are seeking help for various types of problems. Depression, anxiety, difficulties in relationships, work problems, and feeling overwhelmed by life decisions are the most common problems that people report who have come to me for assistance. I work with adolescents and adults. I am privileged to have provided treatment for patients of many different ethnicities, religions, nations of origin, and cultures. Another significant component of my practice is that I teach psychotherapy, which includes providing consultations and supervision for other psychotherapists. My particular expertise as a psychotherapy supervisor is in psychodynamic and psychoanalytic psychotherapy, and I am on the teaching faculty of two local educational institutions which provide training for psychotherapists. Details of my experience as a psychotherapy teacher are found HERE.

I am trained in the use of psychotropic medications and different forms of psychotherapy, ranging from brief therapy for focal problems to long-term, intensive therapies and psychoanalysis for people who suffer from complex, deep, and long-standing difficulties which have prevented them from achieving what they wish to in life. 

I have extensive experience treating professionals, including lawyers, executives, physicians, academics, musicians, artists, performers, and mental health professionals. I have also worked in a university student health service, and I am well-informed about certain problems unique to undergraduate, graduate, and professional students facing academic difficulties or anxiety due to intense academic pressures.

Since the Covid-19 pandemic, I have integrated telehealth into my work. While I prefer to work with people in person, many patients opt for the convenience of telehealth visits and I am flexible about this.

Psychotropic Medications

In the last 20 years, there has been an massive increase in the number of psychotropic medications prescribed in North America. To some degree, this is good news, because it shows that there is less shame and stigma about mental illness, and that people in our society are now more likely than they were in the past to seek professional help when they are suffering emotionally.

However, there is also a negative side to this. Many patients are over-medicated with multiple prescription drugs. Some psychotropic drugs are extremely costly, and many medications have significant, adverse side-effects, especially when prescribed in combination with other drugs. It is every physician's responsibility, first and foremost, to "do no harm," and this would include over-medicating. Many physicians claim that they are careful to never over-medicate their patients, but numerous studies of current prescribing patterns by physicians in North America reveal a very dangerous pattern of "poly-pharmacy," meaning that patients are on far too many medications and at doses which are too high. 

The principles which guides my approach to prescribing  psychotropic medications for patients suffering from emotional difficulties are the following:

1. Accurate diagnosis:
There is a difference between prescribing drugs to target symptoms, vs. prescribing a medication in order to treat the underlying illness which has been diagnosed as being the cause of those unwanted symptoms. For example, if a patient reports difficulty sleeping, one might think that prescribing a sleep medication will be helpful — this is a symptom-based approach. But the problem with this strategy is that "sleep problems" could be a symptom of many different disorders. Major Depressive Disorder, Post Traumatic Stress Disorder, Bipolar Affective Disorder, Obsessive Compulsive Disorder, and Attention Deficit Disorder are just a few examples of the conditions that might cause difficulty falling or staying asleep. These conditions all require different kinds of medication and different kinds of psychotherapy treatment in order to achieve the best outcome. Treating the "sleep problems" with a sleeping pill will not be nearly as effective as making an accurate diagnosis and addressing the underlying disorder. In fact, it might even exacerbate the underlying disorder and cause harm. This is true not only of sleep problems, but also anxiety, intrusive thoughts, indecision, irritability, attentional problems, and many other psychiatric symptoms.

2. Avoid redundant, multiple medications:
All medications have potentially beneficial and potentially harmful effects. This is equally true for prescription medications, over-the-counter medications, or the natural compounds and supplements that are sold in health food stores. (Interestingly, many patients are under the impression that natural compounds and supplements are inherently safer than medications synthesized by pharmaceutical manufacturers. But actually, there is nothing safer about a herbal remedies or supplements — more on this later.) Sometimes, patients see several different physicians and report symptoms of depression or anxiety, and each physician adds another one or two more medications, hoping to be helpful. When a prescribed medication has been partially (but not entirely) helpful, it is common for physicians to add another medication to the regimen. Over a period of months or years, many patients will end up taking numerous medications for the same problem. If we track their symptoms or level of functioning over time, we see that multiple medications are actually causing new symptoms and not solving any of the original problems. Patients are less alert, gain weight from drugs which cause this as an adverse reaction, develop sleep apnea and diabetes from the weight gain, develop sexual and neurologic side effects, become drowsy or groggy with low energy, more depressed, and spend large amounts of money on medications. Also, when there are multiple medications a patient's regimen, it becomes impossible to know which drug is causing each side effect, or which (if any) medications are helping. Furthermore, what might have been minor side effects associated with each drug can become magnified by synergistic drug interactions, and now result in major side effects which can cause serious problems. 

3. Precisely define what we hope to accomplish with any medications prescribed:
It is critically important to define what outcome we hope for when medications are being prescribed. Yes, we hope that patients will "feel better" when medications are prescribed, but we need to be clear in defining exactly "how" people will feel better. For some conditions, this involves making charts to track the severity and frequency of symptoms. For some conditions, it is very helpful to involve collateral reports from relatives and friends, who can supply important information about when someone is improving or getting worse. For conditions such as Attention Deficit Disorder, for example, it is important to track objective evidence of the person's productivity. No patient should be prescribed a medication without clear goals which can be measured objectively, and a clear timeline for how long it might take before positive results should be observed. And it is important to understand that when a psychotropic medication is helpful, the improvement should be very clear to the patient. If a medication “might be helping a little,” then it is probably not helping. Improvements should be very clear to everyone.

4. Make only one medication change at a time, and keep a clear record of exactly what changes were experienced with each medication:
This sounds like a basic idea, but it is surprising how many physicians make multiple medication changes at the same time. This often occurs as a result of the doctor's eagerness to help a patient feel better as soon as possible. But making multiple changes at the same time leads an increased risk of adverse effects, and more importantly it makes it impossible for the doctor or patient to determine which medication adjustment has led to an improvement or which adjustment is causing adverse reactions. It is surprising how many patients with a long history of anxiety, depression, or other forms of mental illness have been on dozens of medications over the years but no one is sure (neither patient or doctor) what the effects of each drug have been. Observing this simple guideline can spare patients needless, unsuccessful trials on medications and help them more quickly find a medication which will be helpful.

5. Use modern, genetic testing when helpful, but realize that the usefulness of this information is usually quite limited:
In the last few years, the mental health field has developed genetic tests (“pharmacogenomics”) in order to help predict people's reactions to various psychotropic medications, including antidepressants, anti-anxiety drugs, anti-psychotic medications, mood-stabilizing medications, and stimulants. This is very exciting progress because it is another step toward knowing in advance which medications are likely to be helpful for each patient, or which are likely to cause adverse reactions. Also, the test is non-invasive and causes no pain. It is covered by most insurance plans, and even when not covered it is offered by the testing company at an enormous discount. These tests are intended to demonstrate the following information based on the genotype of a specific patient: (1) Are there any medications that are unlikely to work for this patient? (2) Does this patient require unusual dosing (higher or lower than usual) for a specific medication to work properly? (3) Are there any medications which the patient is unlikely to tolerate due to adverse side effects? At this stage of the development of this medical technology, these tests can be helpful in determining why someone is experiencing strong side effects to multiple medications, or having trouble responding to multiple drugs. It can also be helpful in establishing a basis to request that one's insurance company authorize a newer, more expensive medication. However, these tests do not yet really offer significant information which helps us more accurately predict which drugs are likely to work. (There is no real harm in order these tests for every patient, but the information generated may not really be helpful in cases where there is no basis to suspect that someone has an uncommon genotype which would require unusual medication strategies. In other words, it is probably not worthwhile to order these tests for people considering psychotropic medications for the first time.)

6. Spend enough time with patients to attend to nutrition, fitness, relationships, and healthy living.
American medical schools still devote very little time in their curricula for nutrition, exercise, and fitness. Because doctors have such a massive amount of information they must learn, medical schools tend to focus on curing illness rather than promoting health. It is also important to note that nutrition and fitness are not a part of the required training during psychiatry residency to become eligible for Certification by the American Board of Psychiatry and Neurology. Yet, there is good scientific evidence that moderate exercise, healthy diet, and adequate sleep can have an immediately beneficial effect on one's mood, anxiety, concentration, cognition, and other facets of one's mental health. In addition, many individuals suffer emotional symptoms in response to many different sources of stress, such as a relationship difficulties, sexual dissatisfaction, work-related unhappiness, financial problems, struggles related to parenting, or vicarious stress due to the suffering of loved ones. Some of these problems need to be addressed in psychotherapy treatment, and it is important to realize that medications are less likely to work when these life problems are ignored. And, finally, there are emotional problems, real-life dilemmas, losses, and trauma which can cause great pain, but which no pill can make better. These emotions, however painful, are a normal part of the process of human growth and maturation and affect even the healthiest and most resilient individuals.

7. Be alert for treatment-resistant depression and consider more efficacious drugs that most psychiatrist are unfamiliar with and have not been trained to use. Starting in the late 1980’s and over the next decades, a new class of medications was innovated by the pharmaceutical and marketed for the treatment of depression and anxiety: Serotonin Specific Reuptake Inhibitors (SSRI’s). These include fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram, vilazodone, and vortioxetine. Then, a closely related class of drugs was innovated starting in the 1990’s: Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s), which includes venlafaxine, desvenlafaxine, duloxetine, milnacipran, and levomilnacipran. Unlike the older classes of medication which were used to treat depression, a major advantage SSRI and SNRI medications that they are very medically safe, and are very unlikely to cause serious harm even in deliberate overdoses. Because suicidal thinking can be a symptom of severe depression, it was a major breakthrough to be able to prescribe medications for patients with depression which are very unlikely to cause harm even during an overdose. The problem, however, is that not everyone gets better on these medications. When a patient has failed a trial of 3 antidepressant medications, we refer to this as “treatment-resistant” or “refractory” depression. Many patients who have failed with trials of SSRIs or SNRIs would in fact be very likely to respond to one of the older classes of medications: tricyclic antidepressants (TCAs) or monoamine oxidase inhibitors (MAO-Is). But because most psychiatrists are not trained to use these medications, they instead continue to prescribe a different SSRI or SNRI, or combine two or three of them. Yet, research indicates that once someone has failed 2 drugs in the same class of medications, the are very unlikely to respond to another agent in the same class, which makes sense given that all the drugs in the same medication class have a very similar chemical structure, and they work more or less the same way in the brain. If someone has failed numerous SSRI or SNRI drugs, then it is very important to seek out a physician who is trained to use TCAs and MAO-Is, because they are much more likely to work for them.

what is Psychotherapy?

Psychotherapy treatments are helpful for wide range of problems. There are many different modalities of psychotherapy, and what all these different types of treatments have in common with each other is that they all involve the patient discussing his or her emotional difficulties with a psychotherapist. The psychotherapist's task is to help the patient develop more successful ways of responding to difficulties, challenges, and emotional distress.

In order to explain how these different forms of therapy work, it will be helpful to use a case illustration as an example. Let's imagine a person who is pathologically shy. He feels lonely because he has no romantic or social relationships. He would like to have a social life, but he is so uncomfortable meeting new people, which keeps him isolated and lonely. He avoids socializing because he fears he will be rejected. Clearly, he needs to develop new ways of dealing with this fear of rejection, because his current method (avoidance) truly sabotages his ability to make friends or meet potential romantic partners. Each type of psychotherapy offers different methods for helping someone develop greater emotional freedom. By "emotional freedom," I mean that the person is no longer limited to only one way of coping with emotional distress. The way this person has coped in the past with his fear of rejection is to avoid showing any interest in others, and to avoid meeting people. If invited to a dinner party, he will decline the invitation. Yes, this does, temporarily, lower his anxiety, because he'd find it very scary to meet new people. However, he is not really choosing to decline the invitation. Rather, he is emotionally incapable of accepting it. In other words, he lacks the emotional freedom to socialize. This keeps him trapped in social isolation.

We want our patients to be freer to make different choices which expand their opportunities for a more fulfilling and meaningful life. The following are several forms of psychotherapy treatment which are all proven to be effective for providing symptom relief for a variety of problems and disorders. When reading through each of these modalities, it may sound as though they are totally different from one another, but the truth is that most competent therapists blend different forms of therapy and make use of whatever techniques and ideas they believe would be helpful for each patient, regardless of what modality or theory of human behavior innovated it. (More on this, below, in the section "Choosing a modality or type of psychotherapy.") I will continue use to use our example of our pathologically shy person, who is unable to develop a social life or love life because of the fear of rejection or criticism.

1. Behavioral therapy: This approach to psychotherapy is based on the idea that a person suffering from an emotional disorder can best be helped by identifying the behaviors which are causing problems. While other approaches to psychotherapy devote most of their energy to analyzing the person's inner beliefs beliefs and emotions and therefore devote their attention to the client's inner feelings of rejection and inadequacy, or his expectations and beliefs that other people will judge him unfairly for any flaw they might discover. However, a behavioral therapist will, by contrast, look at the problematic behaviors which are keeping the patient trapped and isolated. Rather than trying to intervene at the level of the patients subjective feelings or beliefs/assumptions, a behavioral therapist would directly address the patient's actions and behavior. He would assign tasks for the patient to master which would, gradually, bring him into more social contact with others. For several weeks, the therapist might instruct the patient to start saying hello to people. Then he would assign the patient to invite a co-worker to get coffee during a lunch break. The thearpist’s task is to find “bite-sized” changes that the patient can tolerate. Gradually, the patient would be assigned increasingly difficult social tasks. The guiding principle of this form of therapy is that improvement is attained through a small, progressive changes in behavior, and not by understanding what the underling assumptions or deep emotions are which provoke so much anxiety.

2. Cognitive Therapy: This type of therapy (sometimes referred to as "Cognitive-Behavioral Therapies" or "CBT") is probably the most common therapy practiced today, and is emphasizes in most North American graduate programs in psychology. It is based on the belief that the individual who is pathologically shy would find it much easier to become more outgoing after reconsidering, more rationally and logically, why he or she is so afraid to socialize of in the first place. This patient may anticipate being rejected or may fear being ridiculed and humiliated. Cognitive therapy is a process of rational examination of one's fears, anxieties, and other unpleasant emotions. The aim is to use logic and reason in order to neutralize the painful emotions which the patient has, up until now, allowed to run his or her life. Then, more healthful behaviors (for example, meeting others, socializing, making friends, flirting, and dating) become less intimidating. The patient has acquired tools and strategies so that these tasks are no longer so daunting or challenging. In some cases, more healthful behaviors are assigned in a progressive fashion, similar to pure behavioral therapy, with the added benefit of exploring the underlying beliefs and feelings which provoke such anxiety or sadness.

3. Group Psychotherapy: This form of therapy involves several patients meeting with one another in the presence of a psychotherapist who is serving as the group leader (also called "group facilitator"). The group psychotherapist's role is somewhat different here than in individual psychotherapy in that the actual treatment is effected by the various members of the group interacting with one another. There is a shared commitment by members of the group to be respectful but honest with one another. Group members talk not only about the problems they are suffering from in their lives, but also the way they are experiencing one another in the here-and-now interactions of the group process. For example, a person who has problems meeting people do to social anxiety will also have difficulty sharing and relating to people in the group therapy, and other group members will notice this person’s anxiety and address it, directly. The person who sees himself as anxious and shy may be surprised that others feel like he aloof and uninterested in them. This commitment to honest and respectful feedback creates a powerful learning experience where group members see and feel exactly how they are impacting others and how they are impacted by others. Typical groups have between 6 and 10 members. Sometimes there are groups for specific disorders. In my opinion group therapy is most effective for people with relationship problems because, as described above, it is unique opportunity to closely experience the same emotional patterns in the presence of people who are trying to be very understanding and give helpful but honest feedback immediately, in real time.

4. Psychodynamic Therapy: This form of psychotherapy involves helping patients become more aware of the aspects of their thinking and emotions which operate automatically, outside of our conscious knowledge. It is based on a principle that if we remain unaware of the deepest aspects of our motivations and emotions, we will have much less control over our choices and will live much less fulfilling lives. Individuals who benefit from this therapy are people who have been unable to live their lives the way they want to. To illustrate how this therapy works, we will use our same example from above: The individual who is suffering from loneliness but too shy to socialize is not making an intentional decision to avoid socializing. Although he or she in theory may agree that he needs to socialize, meet people and establish relationships, he remains unable to do so because the mere thought of reaching out socially to other people stirs up intolerable feeling states. Avoiding social situations is a way of avoiding the fear of rejection, feeling scrutinized and judged, feeling unattractive, or feeling humiliated. In fact, socially-avoidant people don't only avoid meeting others, but they are so terrified of social rejection that they often convince themselves that they really don't want other people in their lives, and that they are perfectly happy alone. This means that they are devoting huge amounts of energy to distancing themselves from their feelings of loneliness and isolation, their longing for others in their lives, and their fear of being rejected by others. Such patients have very limited freedom. They are in a sort of emotional prison, bound by their own fears and inhibitions. Patient's who have become split-off in this manner from their emotions benefit from this type of therapy because it helps them finally learn to cope with the wishes, fears, and emotions that they have been trying to rid themselves of for so many years. This form of treatment is often extremely helpful for people who are suffering from depression, social anxiety, panic attacks, Post-Traumatic Stress Disorder, relationship problems, excessive anger and aggression, the inability to be assertive, sexual inhibitions, sexual addiction, and long-term problems with self-esteem. It is probably the most helpful form of therapy for personality disorders, including Narcissistic Personality and Borderline Personality.

Psychoanalysis

Psychoanalysis is a more intensive form of Psychodynamic Therapy, which is described above. There are three groups of patients who are recommended to undergo this treatment:  (1) Individuals suffering from long term and complex emotional problems who have tried less intense, briefer therapies and have had insufficient benefit; (2) Individuals who wish or need to know as much as possible about every aspect of their inner thoughts and emotions; and (3) Psychiatrists, psychologists, clinical social workers, counselors, clergy, and other helping professionals who work with people suffering form emotional problems therefore need to be as aware as possible of all their feeling states, triggers, and vulnerabilities. Psychoanalysis involves meeting multiple times each week. It may also involve lying down on couch as a method to help patients concentrate on their inner emotional experiences, though this is not always done. A distinctive aspect of this treatment is that patients are asked to try to perform an impossible task: They to try to report all of their thoughts, feelings, and sensations out loud, in real time as they experience them, with no editing. What happens (usually quite quickly) is that the patient is thinking or feeling things which he or she isn't comfortable saying out loud. This becomes a very powerful method for the psychoanalyst and patient to learn, together, what emotions and thoughts are causing significant distress, and are interfering with the patient's ability to live his or her life in the way he or she wishes to. Psychoanalysts have completed many years of additional specialty training in order to become credentialed to practice this form of therapy. They have also undergone their own extensive, personal psychoanalytic treatment. In addition to being a form of treatment, psychoanalysis offers academics, politicians, business executives, economists, and other thinkers a deep understanding of human motivation. Sex, aggression, competitiveness, love, attachment, pride, accomplishment, fear, shame, abandonment, loneliness, and psychic pain are among the many emotions that and feelings that psychoanalysts believe shape peoples motivations and behavior. 

Choosing a psychotherapy modality and choosing a therapist

With so many different approaches to choose from, patients may wonder how to know which approach is best for them. As mentioned above, most therapists are trained in such a way that the actual therapy they provide involves techniques and interventions from all of the different major schools of therapy. What is more important is that you find a therapist who seems to quickly and deeply understand what you need help with, who listens and gives helpful feedback, and who can describe a plan to help you that makes sense to you. If a therapist can give you a good synopsis of what you’ve described as your problems, offer insights and understanding that you find new and helpful, and lay out a plan that makes sense to you, you are probably going to find the therapy helpful, regardless of whether the approach is behavioral, cognitive, or psychodynamic. You are not expected to “trust” your therapist before your therapist earns your trust. Your therapist should remain professional at all times. Although many therapists are the kind of people that, had you met socially, you could have been friends with, a therapist is not a friend. A therapist is a person who is being paid for his or her professional skills and expertise to help you with your emotional problems. Interestingly, patients often feel bad rejecting a therapist or ending a therapy that is not helpful because it may hurt the psychotherpist’s feelings. This is a very understandable, compassionate human emotion, but you deserve to work with a professional that you believe is helping you. It is your time, your money, and your emotional energy that you are investing in getting help for your difficulties. Therefore, you should feel like the therapist has a good and sensible plan before agreeing to start treatment. Think of the evaluation and assessment as having to goals: (1) The psychotherapist’s ability to assess you, identify the problems or diagnoses that require help, and offer a treatment plan; and (2) your opportunity to evaluate whether the therapist has adequately assessed and learned about your problems, has suggested a plan which makes sense to you, and is someone you have professional confidence in. The initial assessment is a consultation, and after the therapist presents his findings, the two of you will decide if that therapist is the best person for you to see, or if you want another opinion or a referral to a therapists who has a different way of thinking and working which is a better fit for you.