How do I know if what I'm experiencing is normal?

In differentiating between a "mental illness" and the normal fluctuations in mood which are part of all human experience, it is important to consider the duration, frequency and intensity of the symptoms as well as how much the symptoms are affecting your work, relationships and other activities.

Sometimes normal, healthy human emotions, like grief, are confused for a psychiatric condition.  Keep in mind that not all feelings are bad!  Also, everyone is prone to having "bad days" and "good days".

If you're having more bad days than good or if your mood is affecting your work and relationships, it makes sense to get help.  To learn more, click [here].

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What will my first appointment be like?

In the first session, you can tell me why you decided to get help and what you think is important for me to know about you.  I may ask you questions about your symptoms, previous treatment, medical problems, your social life, family members, major life events, etc.  I want to understand what you want my help with and what is causing the problem.  Sometimes it takes more than one session for us to figure this out.

Occasionally I may ask you to have some blood work done, or other testing.  If I'm uncertain about the diagnosis, I may ask that you see another specialist.

If the problem you want help with is something I am familiar with, I will invite you to work with me to create a customized treatment plan.  I will tell you what treatment options are available, the risks associated with each of these and what you are likely to experience.

If the plan is acceptable to you, we can start the treatment immediately.  If you're not interested in the approach I recommend for your problems, I can refer you to someone who uses different techniques or treatments.

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How long before I start to feel better?

This is a very practical question, which is why it's so frustrating that there is no simple answer.  There are many variables that can influence the rate of recovery.  Furthermore, there are many different levels of recovery.  The initial recovery is a tremendous relief, especially if you were feeling hopeless and thought recovery was impossible!  Feeling better is wonderful, but it's not the same as getting better.  Sustained recovery means you have mastered healthy ways of maintaining a positive mood.  It means that even when you "relapse" into depression, you can lift yourself out, on your own.  It means you're using the minimum amount of medication, in a safe way.

Here are some variables that can influence your rate of recovery:

1. How many different problems do you have?
   You may have a mood problem, a relationship problem and an habit or addiction and want help with all of them.  This will obviously take longer than working on a single problem.

2. How motivated you are to work on those problems?
   Motivation is one of the most important variables in predicting outcome.  This is why I will assess motivation regularly during our work and teach you ways of identifying thoughts and beliefs that impair your motivation.

3. How frequently can you meet with me?
   More frequent meetings may result in faster recovery.

4. How long will our sessions last?
   Depending on your needs and preferences, you may prefer sessions that are longer than the usual 50-minute appointment, especially at the beginning of treatment.  A few longer sessions spaced closely together are often more effective than many briefer sessions spread out over time.  Bear in mind that some insurance companies will not reimburse as well for visits longer than one hour.

5. How much time are you willing to invest in therapy "homework", outside of sessions?
   Studies confirm that individuals who do daily psychotherapy "homework" recover faster than individuals who don't do homework between sessions. Recovery from depression, anxiety and bad habits/addictions requires the same kind of dedication and practice as learning a martial art, a new language or a musical instrument.

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How much does it cost?

Please read about my administrative policies [here].

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How do I get my insurance to pay for sessions?

If you are a member of ValueOptions insurance, you will only need to pay me $10 - $50 per session as a co-payment (depending on your diagnosis).  Please tell me if you have ValueOptions when we first talk by phone because I only accept a limited number of ValueOptions patients at any given time.

I do not contract with insurance companies other than ValueOptions, so if you want to know how much your insurance company will reimburse you for our visits, call them (the number will be on the back of your insurance card) and ask them the following questions:

1. How much do you reimburse for mental health services provided by out-of-network providers?
2. Is there a deductible for out-of-network providers?
3. Is there a maximum number of sessions for out-of-network providers?
4. Is there a maximum dollar amount that you reimburse per year for out-of-network providers?
5. Do you offer "single case agreements" for out-of-network providers?  If so, what is the reimbursement rate?

Frequently an insurance company will only reimburse a fraction of what they consider to be an appropriate charge for a visit.  You would be responsible for paying the difference.  Because my fees are often higher than what the insurance company thinks is an appropriate rate, you may end up paying a larger percentage of the actual fee.  Here's an example of how that works:

I highly recommend that you have your visits "pre-authorized" by your insurance provider before scheduling appointments with me.  Even if you have this pre-authorization, it can sometimes be difficult to obtain reimbursement from insurance companies.

I am happy to help you complete any paperwork you have during our sessions and will provide you with receipts of our visits that contain all the information you will need to file claims with your insurance company.  I do not file claims myself, however.

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What is a psychiatric diagnosis?

There is still some controversy about how well psychiatric diagnoses describe underlying brain disease.  Unlike other types of disease, in which we can directly observe the disease process (under the microscope and on X-rays and the like) psychiatric disease is harder to see visually.

Although the brain consists of cells and tissues that can be observed, the mind consists of perceptions, feelings and thoughts. Both the brain and the mind remain something of a mystery to us.  It is still unclear exactly how the mind is generated by the brain and, until quite recently, we were unable to directly observe the activity of different regions of the brain during different mood states, such as "happy", "depressed" and "anxious".

Because psychiatrists could not make diagnoses based on direct observations, they relied instead on "expert concensus" to guide their discussions, research and treatment decisions.  This is an ongoing process that started when experts in the field of psychiatry gathered together to define terms and compare notes about what they were seeing in their work with real patients. These experts gave different names (diagnoses) to the different clusters of symptoms that were frequently found to occur together in many different individuals.  Each of these diagnoses consists of several criteria that describe it.

For example, "Major Depressive Disorder" refers to one cluster of symptoms while "Generalized Anxiety Disorder" refers to a different cluster of symptoms.  In order to be correctly "diagnosed" with a particular illness, an individual must meet all of the criteria listed for that illness.

A complete list of psychiatric diagnoses is available in the DSMIV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision).  The authors of the DSM note that, without special training, it is difficult to use this text properly, and that untrained individuals should not attempt to diagnose or treat themselves or other people.  There are several reasons for this.  For one, there is often overlap between different diagnoses, meaning that the same symptom is often present in two or more diagnoses.

To further complicate matters, individuals frequently meet criteria for several diagnoses simultaneously and it can be difficult to determine which is the better "fit" or if the person has multiple diagnoses simultaneously.  Also, experience counts for a lot when it comes to knowing what certain illnesses look like and what treatments work best. Finally, there can be different causes for any one diagnosis.  Knowing the cause for a particular illness is as important as knowing its name, especially when it comes to treatment.

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What causes psychiatric illness?

This is a highly contested area of debate, even among experts in the field.  Many different factors seem to be capable of influencing our moods in one direction or another.  Our genetics, physical health, hormonal states, alcohol, drugs, medications, as well as nutrition, exercise, sleep, relationships, etc. all seem to influence how we feel.

With that said, the most direct and obvious cause of our feelings, at any given time, is what we are thinking in that moment.  In short, we feel the way we think.  People who feel guilty, for example, are telling themselves something like, "I shouldn't have done that" or "What I did was wrong".  People who feel hopeless do so because they are telling themselves "I'll never succeed, it's impossible".  People who feel angry are thinking "That person shouldn't have done that, what a jerk!", etc.

When a person is able to revise or talk-back to these thoughts, they can feel better immediately:  they might say, instead, "It's o.k., I'm allowed to make mistakes sometimes", "I would prefer to have done a better job, this is a good learning experience", "I wish that person would have treated me better, but that's their problem, not mine", etc.

Some argue that since the mind is produced by the brain, there must be an underlying biological cause responsible for our moods.  Others point out that, without altering the brain with chemicals or electric shocks, many mental activities, such as remembering a pleasant event, meditating or going to therapy, can result in sudden and drastic changes in mood.  It seems that the brain is able to influence the mind and the mind is able to influence the brain.  It may be that when our brains are sleepy, intoxicated and sick, this predisposes our minds to errors in thinking, that then lead to negative mood states.

What this means is that mental health depends on the healthy functioning of the brain (including proper nutrition, exercise, sleep, etc.) as well as healthy functioning of the mind (positive attitudes, self-respect, good communication skills).  With determination and practice, you can achieve your greatest potential for health and happiness.  I can help!

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What are the advantages of being correctly diagnosed?

There are several advantages to knowing the name of the illness that you have.  One advantage is that you will be able to make informed decisions, with your psychiatrist, about what treatments are likely to help you.  A great deal of research has been done to collect evidence on how well these various treatments work and what the side effects are.  This can improve your odds of recovery and reduce the amount of time spent feeling bad.

Another advantage is that the fear of the unknown will disappear and you will discover that you are not alone and that literally millions of other people have experienced the same thing you are experiencing.  For example, according to the NIH (National Institutes of Health) one in every nine Americans has experienced Major Depression at least once in their lifetime and one in twenty have experienced Major Depression in the last year.

Also, if you have a diagnosis, your insurance company may reimburse you for your treatment, making it financially possible for you to get the treatment you need.  Recent legislation has made it illegal for insurance companies to deny you coverage if you have one of the more serious psychiatric diagnoses, including Major Depression, Bipolar Disorder, Schizophrenia, Schizoaffective Disorder, Panic Disorders, Obsessive Compulsive Disorders, Bulimia Nervosa, Anorexia Nervosa and several others.  That doesn't necessarily mean that any given provider will take your insurance, however, and there can sometimes be a waiting list for providers who take insurance.

You can find a lot of information on the internet about psychiatric diagnoses. Keep in mind that this information does not substitute for evaluation and treatment by a professional:

• www.nami.org
• mhanational.org/find-support-groups
• allpsych.com/disorders/mood/bipolar
• www.behavenet.com/apa-diagnostic-classification-dsm-iv-tr

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What are the disadvantages of having a psychiatric diagnosis?

Although it can be a relief to get a diagnosis and be on your way towards effective treatment, there are also drawbacks.  One drawback is that when someone is diagnosed, they may feel embarrassed, ashamed or defective because of this "label".  Many people with depression already feel worthless and defective, so adding a label can be like adding insult to injury.  This is another reason to make sure you are correctly diagnosed and have the support of a professional during this process.

We all know that "nobody is perfect" and that huge numbers of happy, successful people have mental illness.  This may not be reassuring, however, because depression and the shock of the initial diagnosis can make it hard to "believe" or "feel", at a gut level.  It can take time to prove to yourself that you are capable of having a fulfilling life regardless of any "diagnosis".

As discussed above, it is still a little unclear how valid these diagnostic labels are and they certainly don't define anyone, even if they are correct, any more than our eye color or the color of our skin.  Still, that doesn't mean you won't be upset when you are told that you have a "mental illness".  If you feel ashamed or bothered by a diagnosis you have received, this is a good thing to talk about with a professional.  Many people benefit from support groups, such as those offered by NAMI (National Alliance on Mental Illness) especially when they are first diagnosed.  You can learn more about NAMI [here].

There can be other disadvantages to being diagnosed.  Despite legislation designed to eliminate discrimination, such as the "Americans with Disabilities Act", some businesses still treat people unfairly, based on a prior history of illness.  These include some life insurance companies and some private health insurance companies.  Also, certain employers may ask whether you have been treated for any mental illness in the past.

Before receiving treatment, filling a prescription or filing an insurance claim, you may want to discuss with me or a legal professional the risks and how to minimize them.  There are National and State groups that are working towards creating greater equality and fair treatment for individuals with mental illness.  If you want to get more information or become involved, call SAMHSA's National Mental Health Information Center at 800-789-2647 or visit their website.

If you would like to learn more about my policies regarding confidentiality and privacy, click [here].

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Will it be hard for me to get insurance in the future if I am treated for a mental health condition?

Most people receive medical insurance benefits through their employer. However, if you lose your job, you can lose these benefits and may have to obtain private medical insurance.*

Private insurers may ask you whether you have been treated in the past for a mental illness.  They may ask you to release records of any previous treatment.  Private insurers use the information about your previous treatment to determine how much to charge you for coverage and they may not offer you coverage at all, if they discover a history of previous treatment.  This is one reason why you may prefer to see a provider outside of your insurance coverage.  See also my Policies on privacy and confidentiality.

One way to determine whether you would be eligible for the private insurance you would like to have after being treated is to call the company anonymously and ask them if they will provide you with a policy and say that you have a history of psychiatric illness (you could say "major depression" if you don't know what your diagnosis is).

* In California, you have the option of enrolling in a program called COBRA that continues the medical insurance policy you had at your last job for a year or longer, but you still have to pay for this out of your own pocket.

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Will it be hard to get a job in the future if I am treated for a mental health conditiont?

Some jobs, especially higher-level positions in certain Government agencies (the CIA, for example), ask that you disclose information about previous psychiatric treatment.  If you have had psychiatric treatment and you do not disclose this information (and it is discovered), you could lose that job.

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Who can get access to the notes you take during our sessions?

You can read about this on my administrative Policies page.

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What are your qualifications?

Please see my biography [here].

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My friend or family member needs help.  Can you see them?

If your friend or family member is ill, it can be a very stressful situation for you.  For example, your loved one may be suffering tremendously from depression and not have enough motivation to call for help.  They may even resist your efforts to find help for them.

In the case of an emergency, you must act swiftly and decisively.  If you suspect that they are a danger to themselves or others, for example, you should call 911 or go with them to the Emergency Department immediately.  Remember that it's always better to be safe than sorry!  They may thank you, later, for saving their life.

Please note that the therapy I offer is not intended for people who are actively suicidal or experiencing other types of psychiatric emergencies.  I only offer treatment to individuals who can safely participate in the therapy.

Because successful therapy outside of the hospital requires active participation, one measure of whether someone is ready for this is if they are willing to make that first phone call.  This also gives them a sense of accomplishment and mastery over the process of recovery.

If your family member or loved one isn't motivated enough to call, it's unlikley that they will be motivated enough to participate and benefit from the type of therapy I offer.  This is why I prefer to speak first with the person who will be my patient.  That way they know I'm working for them and they get the message early that their participation isn't just important, it's necessary.

You may have extremely useful information that could help them recover.  If I am already working with a friend or relative of yours and you believe they are in danger, please contact me immediately.  Once I have begun meeting with the patient, you are welcome to volunteer any information you may have.  Unless it is an emergency, I recommend you discuss this with the patient ahead of time to avoid complicating your relationship with them.

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Do you treat children?

I do not have specialty training in child psychiatry and therefore do not work with children.  On rare occasions I will consult in the care of adolescents, for therapy only, if I have their parent's permission and if this treatment is recommended by the child psychiatry specialist who is overseeing their care.

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