Before discussing the specific anxiety disorders, it should first be understood that the way anxiety symptoms are experienced differs, falling into three general patterns.

Unfocussed Anxiety

Here, anxiety symptoms are not connected with any recognizable stimulus to trigger them. Unfocussed anxiety, depending on the particular disorder experienced, may come as if out of nowhere, or alternatively, may be experienced continuously.

Focused Anxiety

Here, the anxiety is associated with recognizable triggering stimuli or situations.

Compulsive Anxiety

Here, anxiety occurs in the absence of performing a particular thought or behavior requirement which, once complied with, alleviates anxiety (temporarily).

There are two types anxiety disorder characterized by unfocussed anxiety. Generalized Anxiety Disorder (GAD) and Panic Disorder.  In Generalized Anxiety, one experiences continuous unfocussed anxiety symptoms that cannot be attributed to any particular source. Sometimes the anxiety experienced is described as “free floating,” leaving the sufferer with an impending sense of non-specific dread, unable to say what they fear might happen.  Because of their pervasive fear of the unforeseen and unforeseeable, one may imagine how sufferers become crippled with the inability to make decisions or to enjoy life, even when things (“only seem to be . . . “) going well. When unfocussed anxiety is exhibited in discrete episodes or attacks, rather than continuously, this describes Panic Disorder.

Focused anxiety disorders include the phobias, which involve irrational an fear of a known stimulus, combined with avoidance of the situation or stimulus that triggers it. In a previous article on anxiety, fear was differentiated from anxiety on the basis of the stimulus being “known.” The apparent contradiction is resolved by understanding that while the trigger stimulus in a phobia is recognized, the basis for the irrationally extreme reaction to it remains mysterious. One former had an inordinate fear of spiders (i.e., “Arachophobia”). One rainy night while driving on the highway, she thought she saw a tiny spider dangling from her rear view mirror. Her response was to scream, close her eyes, let go of the steering wheel, and lock-up the brakes. She skidded to a spinning stop that could easily have been fatal. While the trigger stimulus was well recognized, the reason for her potentially catastrophic excessive reaction to a harmless spider begged for understanding and resolution.

Phobias are quite common, involving fears of specific objects such as particular animals, as illustrated above, or fear of situations such as of heights (Acrophobia), closed in spaces (Claustrophobia), leaving home (Agorophobia), or fear of certain social situations (Social Phobia). Depending on the nature of the fear stimulus and the extent of phobic avoidance, a phobia may pose minimal inconvenience in ones life, or it can drastically disrupt the ability to live a normal life. A phobia of sharks in someone living in-land, for example, is unlikely to often cause much bother. On the other hand, agoraphobia may be debilitating to the point that the individual becomes house-bound, unable even to venture out for needed treatment.

Post-Traumatic Stress can also be considered as a disorder characterized by focused anxiety. After surviving a traumatic experience, the sufferer develops anxiety symptoms associated with the trauma and stimulus triggers reminiscent of the traumatic situation.

Obsessive-Compulsive Disorder involves the feeling of having to engage in (often unwanted) repetitive thoughts, actions or rituals. These compulsions serve to relieve the unwanted obsessive ideas that plague the mind until the compulsion is performed. Only then is relief from anxiety granted, albeit, only temporarily. Ritualistic compulsions are many and varied, often involving cleaning or organizing rituals, the need to avoid stepping on cracks, ensuring one wears certain colors on particular days, etc. While it is very common to exhibit minor obsessions with their accompanying rituals, most people seem to know recognize someone in their sphere with a serious compulsions that overtake their life.

Individuals with well-developed anxiety disorders invariably recognize they have a problem. They often chide themselves for allowing “such a silly thing” to disrupt their lives as much as it does. Unfortunately for those who try so hard on their own without success, the solution to these difficulties often lies obscured by our psychological blind spots. If you, or someone you know, has been battling anxiety too long without improvement, they should seek professional assistance before more of life passes them by.

Generally speaking, the technical use of anxiety refers to the subjective experience of apprehensiveness, uncertainty and helplessness in response to some as yet unrecognized factor within the self, or to some event in the external environment. When associated with an external event, there is no actual threat of danger. In addition to the subjective feelings noted above, one is also typically aware of physiological changes, including irregular breathing, tension of the skeletal musculature (e.g., weakness, shakiness, stiffness, etc.), cardiovascular changes (e.g., rapid heart beat, palpitations, increased blood pressure), and gastrointestinal changes (e.g., nausea, diarrhea, vomiting).

While beyond the scope of this article to go into exhaustive detail, there are several major distinctions that have been drawn in the basic understanding of anxiety.

Anxiety Versus Fear

Where anxiety, by definition, is a response to an unrecognized stimulus, when the associated stimulus (either internal or external) is recognized, the subjective response is distinguished as a “fear.” The reader who recognizes that phobias, by definition, have known triggering stimuli may object to this distinction, since phobias are classified among the anxiety disorders. In a subsequent article on specific disorders, I will address why this is not a contradiction.

Manifest Versus Latent Anxiety

Manifest anxiety refers to the experience of the emotional and physiological signs of anxiety noted above. Latent anxiety refers to anxiety that is active but not seen. This latency may refer to one with a predisposition to respond with anxiety.

Conscious Versus Unconscious Anxiety

Conscious anxiety refers to the subjective anxiety response that the suffering individual can recognize and report feeling. Unconscious anxiety, by contrast, refers to physiological or behavioral expressions of anxiety in the absence of any feelings of being anxious. An individual who exhibits phobic avoidance without awareness of any feelings or physiological signs of anxiety could be described as exhibiting unconscious anxiety.

Primary Versus Signal Anxiety

Primary anxiety, in psychoanalytic theory, refers to the utterly overwhelming emotional experience exhibited when defense mechanisms fail to contain primitive and repressed material in the unconscious. This is commonly experienced in a very normal way in the occurrence of nightmares, where themes of fragmentation and annihilation are ubiquitous. Similar themes are also easily discerned in childrens’ stories like Humpty Dumpty, and in adult horror films where the most terrifying images are of victims pursued by forces of unseen but certain destructiveness. Signal anxiety is the internal warning mechanism, alerting the system to the stirrings in the unconscious that threaten equilibrium. Signal anxiety activates defense mechanisms to ensure primary anxiety does not intrude on consciousness.

This article has told you nothing about anxiety disorders that we hear about, such as social phobia, panic disorder, and obsessive compulsive disorder. Instead, the focus here has been to provide some conceptual and theoretical background to the anxiety construct as a basis for a discussion, in the next article, about specific anxiety disorders that you or those you know may have experienced.

If you need to get in touch with me to talk about anxiety therapy and counseling options just fill out a “contact us” form or call my office.

Define the Problem

A favorite professor of mine used to be fond of saying that “the solution was never found to the problem that was never defined.” The problem must be accurately identified. In so doing, it is important to keep in mind there is a natural inclination in us all to a certain type of biased thinking. The “fundamental attribution error” biases us towards attributing our own negative behaviors to causes that are 1) situational and 2) external to us, while the undesirable behavior of others is overly attributed to factors that are 1) enduring and 2) internal. In the example above, Amy does not attribute Chris’ behavior to a temporary, treatable condition (depression) that has afflicted him, but rather to stable, internal characteristics of Chris’ (that he has changed and no longer loves her or wants the relationship). Mistaken assumptions about what is wrong make one’s own suffering worse, and can easily lead to unnecessary choices that harm the relationship. Question your assumptions as you strive to define what is wrong. Be vigilant for the fundamental attribution error.

An interesting twist on the fundamental attribution error occurs when a reversal of the usual pattern is seen in depressed individuals. Chris, for example, also fails to recognize it is depression, and assumes it is something wrong with him, even though he asserts he didn’t know what it was.

Resist Blaming and Shaming

The attribution error is often related to blame. Both Chris and Amy, for the most part, blamed Chris for what was wrong. Many people blame themselves for failing to make their (depressed) partner happy. Blaming escalates to shaming with the attitude that “I (or you) should just ‘snap out of it’!” A mopey attitude one should “snap out of,” but Depression? I am still waiting, after 20 years, to hear of a case where this has happened so easily.

Accommodation

Adjusting expectations of what a depressed individual can accomplish will likely be necessary, however, it is important not to foster excess disability by “taking over” for them. Re-negotiate responsibilities and expectations, with the expectation that your depressed partner can and will do what they agree to. Be flexible about re-negotiating, as necessary, and support and encourage them in doing as much as they can. Maintain a view to increasing expectations as they are able.  If you think of a depressed mind like an injured muscle, it is important to reduce the stress of demands on the weakened muscle, but not too much, or it will atrophy. Regaining full strength, however, requires more than just waiting at reduced demand: progressive challenge and demand is necessary to foster recovery.

Commit a Daily Act of Defiance

Depression undermines us from the things we normally do, and alienates us from living and enjoying life fully. It is important to think of ways to undermine the depression that is undermining us. Remember the phrase “defy the impulse.” Defy the impulse to stay inside, to sleep all day, to talk to no one, to do nothing. Whatever depression is “telling you to do,” look to defy it in any way you can, even in the smallest amount. A short walk every day with your partner brings benefits of movement, exercise, fresh air, and restoration of the companionship that has been adversely affected by the depression.

Talk About Feelings

Share your feelings, even if just a little, with your partner. I remember an elementary school teacher once telling my class “no one ever learned anything while their mouth was open” (talking, presumably). From the point of view of classroom management, I suppose this is a serviceable principle, but psychologically it is simply untrue. Expressing our thoughts, feelings, and experiences has a way of changing how they are experienced, usually for the better, by clarifying, containing, or alleviating it by “getting it off [your] chest.” While this may come to us by way our partners’ responses, it does not depend on it. Consequently, partners need not feel the pressure to have answers. Being present merely to listen can, in itself, be tremendously helpful.

Read, Read, Read…

Read about depression. Everyone who is reading this has access to a computer. Read some more. At the start of the learning curve, reading more invites confusion due to conflicting opinions and advice you will read. I challenge you to keep reading a bit more and see if things don’t begin to fall into place, leading to your quickly developing a surprisingly sophisticated understanding. One can be easily forgiven for not understanding the basic function of gluons in . . . whatever field of study it is that recognizes them. It astounds me, however, how little people actually know about depression, given that everyone knows of its existence.

Seek Professional Help

Depression is sometimes called the “common cold” of mental health, no doubt because it is so common. Unlike the common cold virus, it is highly treatable. Perhaps it is more akin to “the common computer virus” of mental health, because while treatable, when people become afflicted, they don’t respond with improved self-care, or seek professional help in a timely manner. Their defenses are disabled, making their responses to the affliction progressively less effective until, eventually, at long last, it dawns on them what is wrong. Once recognized, only then is it possible for appropriate, effective action to be taken.

Amy S. (not her real name) initiated therapy to discuss relationship problems. Amy was 32, and had been married to Chris, 33, for 4 years, after having dated for 2. They met through friends who shared their mutual interest in outdoor activities including hiking, camping, and cross-country skiing. They are both professionally employed in related fields of work that both find challenging, at times stressful, but generally engaging and rewarding. They enjoyed their social life with friends and family, participated regularly in mutual (hiking, skiing, folk-music listening) interests as well as pursuing individual hobbies (motorcycling, vs. arts-and-crafts and scrapbooking).

Amy complained that she could not pinpoint when, but over the preceding 12 to 18 months she had begun feeling dissatisfied with certain changes in Chris. She reported he no longer engaged in much conversation at home as before. “It used to be we talked openly about everything, lamenting “it’s a big part of who we were.” She observed that Chris had withdrawn from her and that, increasingly, when she tried to talk to him, not only was he uninterested, he was distracted and seemed not to listen to her. It had been months since they participated in any of their hobbies, and the last few times they did were no fun, as “he wasn’t into it.” Their previously satisfying sex life had also become non-existent. Amy felt hurt, sad, but also angry at being rejected by Chris. It was obvious to her he did not did not desire her, feared he may no longer love her, and wondered if he had effectively left the relationship. When she confronted him directly, he told her “I don’t know what’s wrong, I really don’t know what I want anymore, but I’m just not feeling it.” Amy was understandably devastated, and since then always felt herself “on egg shells” at home, just waiting for the “other shoe to drop.”

Amy presented a compelling description of “problems at home,” and was quite rightly alarmed that the situation was serious and could not continue as it had. Perhaps the most serious and immediate aspect of the crisis was that the problem had been wrongly defined by Amy. Their relationship was actually not “on the rocks.” Chris’ lack of participation, which was certainly very real, was not the primary problem, but instead a consequence of his unidentified depression. In an earlier blog article, I discuss depression and its symptoms in some detail, and the reader is referred back to that earlier post for background.

This vignette about Chris and Amy illustrates quite well how symptoms of depression can be expressed in daily life, and how their impact is often expressed in one’s intimate relationships. It may seem remarkable that Chris’ depression was not identified before, but he did not feel especially sad and blue. While a depressed, sad mood is commonly thought to be a defining feature of a depressive disorder, it is not actually the case. Many depressed individuals never actually “feel depressed” in this sense.

When I met with Chris, it became readily apparent that what Amy took as distracted disinterest was actually an inference based on the outward signs of Chris’ difficulty concentrating and thinking. This, combined with a lack of energy, also a symptom of depression, made Chris look like he “couldn’t bother to pay attention.” The truth was, he was unable to pay attention as before. Lack of energy, fatigue and disrupted sleep were also behind many ways in which Chris no longer took initiative in the relationship. What appeared to Amy as no longer caring about shared interests was clearly related to these symptoms, as well as to social withdrawal, which is another typical symptom of depression. Loss of sex drive is also common, which Amy mistakenly took as a rejection – that Chris was no longer attracted to her. By far the most devastating symptom of depression affecting the relationship was Chris’ anhedonia, or lack of interest in and joy gained from things that used to bring pleasure.

The most insidious aspect of anhedonia here–something I have not read in the professional literature about depression—is the way it went beyond merely denying Chris of interest and pleasure, it deprived him of desire. It is one thing to gain no pleasure or feel no interest, but to have no desire strikes deeper. Desire functions in the psyche like an emotional compass, giving us direction, while interest and joy propel us along that path of what we desire. To lack interest and joy is to be stagnant, but to lack desire is to be lost and adrift. For Chris, lack of interest and joy manifested in not wanting to go out, or participate in the usual activities. Lack of desire, however, caused him not to know what he wants, including his relationship with Amy.

To be continued…

In Canada, most medical care is typically accessed via the universal, socialized public health care system. Dental care among other services, on the other hand, is accessed in the private, fee-for-service sector. With limited exceptions, these services may all be described as conforming to a single-tier model of service distribution.

Psychological service, however, is quite different to the extent that it is widely available both within the public medical system, as well as outside it in the private sector. Because the same services offered within the public system are also available in the private sector, this effectively establishes a two-tier system.

We Canadians love and hate our universal healthcare, but from my experience, mostly we love it. When encountering difficulties associated with public system limitations, we remind ourselves of our good fortune with tales about problems in other countries, such as the U.S., where the costs of needed medical services can be financially devastating or worse–unaffordable and, consequently, unattainable with dire consequences.  In a two-tier system, patients have a choice between publicly provided and privately purchased services.

Because mental health care (and particularly psychological service) is distributed across two-tiers, the emphasis here is to clear up confusion by presenting the main benefits and limitations of the public system in order to illuminate the advantages, in many instances, of private sector alternatives. Prospective consumers of psychological services, it is hoped, may then better appreciate the circumstances under which they would be better served by the private sector.

I began private practice work over a dozen years ago with some uneasiness, knowing, as I did, that there were good psychologists working in the local hospital system where tax dollars, not out-of-pocket fees, “pay the bill.” It seemed unethical, if not dishonest, not to ensure clients knew where and how to obtain similar services “free.” I soon learned that most clients come to me out of deliberate choice to avoid the public system rather than ignorance of its availability.

The public health care system has a single advantage over private sector services: it is free! And were it public system adequate in what it provides, it is certain that psychologists could not earn a dollar in private practice. No one will pay out of pocket if they can obtain the same service at no cost. The reality is, the services available are not really the same. There are important limitations in the public system, and many people are confused and frustrated in their efforts to obtain needed help. They are uncertain where they should turn, and unaware what considerations should inform their choices.

To highlight the differences with an analogy, public mental healthcare can be likened to public transit. The public transit system was designed as a solution for the masses, and when evaluated at that level of service–to the masses–it can be seen to perform very well. By design, however, the public system is very different than personal transportation. It is completely insensitive and unresponsive to the needs and preferences of the individual. The individual must accommodate to what is offered, tolerating the limitations of (among many things) availability, access, convenience, flexibility and quality of service in the hopes that at least their most basic goals will eventually be, more or less, acceptably addressed.

Point of Access

Public outpatient mental health services are accessed by referral from a physician. Private services do not require a referral. While informal referrals or recommendations are commonly offered by other professionals, clients typically seek psychological services directly.

Timely Access

Community psychiatric and public system-based psychological services typically involve waiting lists rarely less than several months in duration and wait times well over a year are common. Wait times for private sector psychologists, in my experience, rarely exceed one week.

Restricted Range of Services

Within the public sector there are many areas where there are gaps in the services provided. Furthermore, for any given issue, there are typically multiple treatment options. If one is not satisfied with the treatment model offered, there is no option but to look to the private sector where a diverse range of options is to be expected.

Service Limits

Many service programs have arbitrary limitations (e.g., 6-session therapy) having nothing to do with actual clinical needs, and everything to do with institutional constraints.

Service Availability

Public system services that are technically available usually have restrictive (often undocumented) selection criteria that are convenient for the program providing the service. I have often heard complaints by physicians about the bewildering refusal of programs to accept patients who met a service program’s explicit selection criteria.

Choice of Care Provider

In a system where services truly are in short supply and very much rationed, patients have limited opportunities to request other providers, should those initially assigned prove unsatisfactory. Requests for a “second opinion,” while not at all unusual in the private sector, are viewed in the public sector as reflecting an attitude of entitlement, and often taken as an insult to the care provider.

All practitioners were once students, and by contrast with other areas of healthcare, in mental health there is simply nothing useful to be learned from plastic models, fetal pigs and cadavers. There is no other way to gain practical experience than trial-by-fire with real patients, and almost all such training happens in public system facilities. One always has the right to refuse care from a student provider, but the practical reality is that so doing frequently means longer wait times for service.

Quality of Care and the Economics of Accountability

While much could be said here, it boils down to the simple reality that employees must satisfy the requirements of those who pay them. In the private sector, where the professional is paid directly by the client, let it suffice to say the incentives for performance are very different than in the public system.

While needing to meet certain (usually fairly high) training standards in order to be hired into public systems, there is little formal incentive to actually be effective, clinically, or even to make an effort. In the private sector, those who are skilled and work hard tend to be rewarded directly by clients who stay with them, and recommend others. In the public system, success is usually defined in terms of conformity with administrative needs, such as timely submission of (invariably arduous) paperwork.

Public Health Records and Confidentiality

Health care professionals are ethically required to maintain records of their professional contact. Those working in public institutions also must also meet their employers’ specific requirements for record keeping. Once treatment is concluded, patient files are usually transferred to a central records department where they are stored for years. While these records are considered “confidential,” they are not “privileged,” and can be legally accessed by other professionals involved in the patient’s care. This is sometimes, but not often, a concern to patients. More cause for concern is seen in cases where patients on long-term disability are coerced to “consent” to their records being disclosed to their insurance provider as a condition of continuing to receive benefits. I know of many clients who were concerned their records might be subpoenaed as part of a legal action (e.g., a contentious divorce, or ongoing insurance litigation). A recent Alberta Appeals Court decision made an important ruling upholding a psychologist’s right not to keep records at the insistence of a patient who was concerned about her records being subpoenaed. It is unlikely that a public system would permit a psychologist in its employ to exercise this option.

Despite the number of drawbacks to the public system, it remains an important resource in certain circumstances. Here are a few guidelines to help inform your decisions.

You should use the public, universal system:

1. If your life is in immediate jeopardy from the irresistible urge to commit suicide, you seek immediate care from your family doctor. If he or she cannot see you the same day, then a walk-in clinic or hospital emergency department should be your next destination.

2.  If you suffer from a condition so severe and debilitating that you are unable to attend to basics of self-care needs, this suggest you may require hospitalization and psychiatric attention.

3. If you have other mental health care issues, but due to financial limitations, simply cannot access private sector services, you should seek out what (if any) public system services may be available by referral from your family doctor.

4. If you have other mental health care related issues, but don’t mind limitations of access, timeliness, quality of service, and choice of service and service provider, then you may be satisfied with public services that may be available through referral.

If the above four points do not compel you to use the public system, then you should consider the private sector for the therapy services you seek. Within the private sector, you may expect a broader range service types and options, with choice among practitioners with varying training and experience backgrounds to suit your individual needs and preferences. Private sector services are typically available with minimal delay, from psychologists who, in my experience, are ready to explain their services and methods, and also to recommend other professionals when their offerings are not a good fit to your needs. In my own practice, I typically field several calls a week from individuals needing guidance in determining the type of services that would be most helpful. Frequently these fall outside my practice areas, where I am glad to provide recommendations to colleagues who I believe would be more helpful.

Some risk factors include:

Gender – Depression is twice as common among women.

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Family psychiatric history – Depression is more likely with a family history of depression, suicide, or alcoholism.

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Personal psychiatric history – A prior history of depression increases the risk of future episodes, as does a history of trauma, past or present alcohol abuse or substance abuse. A number of personality disorders predispose individuals to depressions.

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Loneliness and isolation – Loneliness increases the risk of depression, and once depressed, isolation all-too-often becomes a natural inclination that only perpetuates the depression.

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Medical condition – Serious or chronic illnesses (e.g., cancer, HIV/AIDS, heart disease, dementia) as well as hormonal problems (e.g., hypothyroidism) increase the chances of depression. Related to this, some medications increase the risk as a side effect.

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Stress – Stress is a deceptively complex topic, yet one that can be simplified for the practical purposes of this discussion. Stress is an external demand or pressure on the “system.” Stress is the universal risk factor, complication factor, and impediment to cure. I have yet to hear of a physical disease or psychological disorder where stress is not named as a primary culprit.

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Financial strain – Poverty is, itself, a type of stress that induces worry, but it should be singled out for discussion because of what can be considered a multiplier effect: without sufficient finances, otherwise minor annoyances become more significant inconveniences (e.g., a bill payment coming due), or even life threatening issues (e.g., cold weather, hunger).

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Personality traits – Certain personality traits, such as pessimism and low self-esteem increase the risks of depression.

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Social support– The relationship between social support and depression is stronger than the relationship between cigarette smoking and lung cancer. The lack of available supportive friends and family makes us vulnerable to depression and hampers recovery. Relationships that provide “negative support” (e.g., tension, conflict, and criticism) are especially important to take note of, because the impact of one negative relationship has 25 times the magnitude of just one positive relationship.

A diagnosis of depression is made based on the presence of a number of symptoms from a list including:

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• Loss of energy, or feeling fatigued.
• Disrupted sleep pattern (either too much, or too little).
• Disrupted ability to concentrate or make decisions.
• Feelings of worthlessness or excessive guilt.
• Preoccupying thoughts about death.
• Physical lethargy or agitation.
• A change in weight by more than 5%.
• Anhedonic depletion (loss of pleasure from, or interest in things that used to bring joy).

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It is important to recognize that one need not exhibit all these symptoms for a diagnosis. It is often wrongly assumed that to have a diagnosis of depression, one must count a depressed mood among their distressing symptoms. Many individuals, however, exhibit anhedonia, but not a sad, depressed mood, and it is not unusual for them to fail to recognize they have a condition requiring help. If you think you may be suffering or experiencing the above mentioned symptoms contact me for consultation.

> Fields concerned with understanding and treating disorders of the mind.
> Both address diagnosis, case formulation, treatment planning, and treatment delivery.
> Psychiatrists and (most) psychologists are both addressed as “doctor.”
> Both fields are actively engaged in research in a range of areas of shared interest. It is not unusual, for example, to see psychologists publishing in psychiatric journals.

Because of these similarities, it is not unusual for people to seek the services of either a psychiatrist or a psychologist for their difficulties. But before you toss a coin to choose, you need to know about our differences. In probably the majority of cases, those differences will impact the care you receive in ways that matter to you.

Are you a person or a disease? Psychiatrists come from a background in medicine, and are naturally taught to conceptualize life’s problems in a medical framework, as diseases. The diagnosis is their understanding of the problem, and the treatment for patients’ diseases, most often, is medicine. While psychotherapy used to be a mainstay of both psychologists and psychiatrists, it is rare to find a psychiatrist these days who received much training in therapy, and rarer still to find one who practices it well.

Psychologists come from a psychology background. Their broad-based grounding in the many areas of human behavior serves as the foundation for specialization in such areas as abnormal behavior and its treatment. When conceptualizing patient problems, psychologists may use formal diagnosis, but only as the starting point, rather than the end-point of their deeper and broader understanding of the individual with his or her problems, strengths and vulnerabilities. Psychologists frequently use standardized psychological tests to greatly aid in problem assessment and treatment planning. While the interview method is indispensable, it is limited by fundamental problems, such as with it’s sensitivity, reliability and validity.

Because psychologists are not physicians, they are not trained or qualified to administer medication. Because psychiatrists are trained as medical practitioners, not scientists, they do not have the psychometric background to understand and interpret standardized tests like the MMPI, Rorschach Inkblot Test, or tests of intelligence and cognitive functioning such as the WAIS that can vastly improve reliable and valid problem assessment and treatment planning.

A pill for every ill? Psychiatric medicines are cheap, accessible, and with ever-fewer side effects, easier to swallow now than ever. For these reasons, it is understandable that medication has become a first-line treatment approach. Unfortunately, pharmacotherapy has been vastly over-sold based on promises it can’t fulfill. Its limitations, however, become serious problems for patients when medication is so often the only line of treatment considered by physicians. The majority of clients I’ve seen (over 90%) had been on medication prior to seeing me. Most had been tried on multiple drugs and numerous dosages over periods ranging from many months to several years. All were dissatisfied. Faced with inadequate treatment outcomes, most physicians offered their patients yet more medicine, or counseled them to lower their expectations. Only the rare exception has suggested their patients consider psychotherapy. The majority of clients tumble to the idea of psychotherapy on their own, or from sources other than their trusted family doctor.

An interesting trend I have seen recently is the increasing number of people who are not interested in taking medicine. For some, it is a lack or loss of blind faith in medicine. For others, it is a view that psychotropic medications, even if effective, can only mask symptoms without resolving the real underlying issues. Still others view taking medicine as a form of submission where any benefits come at the heavy cost of giving up hope that they can do something to help themselves. For them, psychotherapy is preferred as a mutually collaborative process that empowers them as the agent of change in their own life. I am sympathetic to all of these concerns.

A yellow brick road to nowhere. The classic movie, The Wizard of Oz, portrays three unfortunates, each tortured by a different deficit in a major domain of psychological functioning. One longs for adequate mental capacity, another is crippled by undermining inadequacy and emotional turmoil, while a third lacks for feelings needed in order to enjoy satisfying relationships. Each of them, with a flawed perception of the problem and misplaced hope in a powerful wizard, travels long and far for his false remedies. In the end, real solutions came unexpectedly through a fellow traveler who helped them find within themselves what they thought was lacking. Now seeing themselves and the world differently, they were transformed. An unseen internal barrier was removed which liberated a vital aspect of the self to be experienced and expressed. This is where I realized the exciting and powerful potential for a career where I could make a real and positive impact in the lives of others.

Every one of us experiences or exhibits difficulties that are perplexing. Blind spots in awareness prevent accurate self-perception and confound productive self-understanding. Unless we can remove our blind spots, we cannot truly resolve our difficulties.