Episode 22: Psychiatric Health and Care

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Episode Summary:

Recognizing and managing mental health episodes and conditions can be particularly hard for guys, who tend to deal stoically alone with the hard stuff in life. Early, multi-pronged, context-based treatments are successful and available for anger management, depression, and other psychiatric and mental health situations.

Episode Guests: 

Mack Black, M.D. Assistant Professor of Psychiatry and Behavioral Medicine at the University of Washington School of Medicine; Attending Psychiatrist at Harborview Medical Center.

Brian Poeschla, M.D. Associate Professor of Psychiatry and Behavioral Medicine at the University of Washington School of Medicine; Attending Psychiatrist at Harborview Medical Center; Director of Intake and Brief Intervention Services in Psychiatry at Harborview; Consulting Psychiatrist.

During This Episode We Discuss:

  • Two psychiatrists (who work in an acute care psychiatric facility) review more serious mental health issues.
  • Information for individuals concerned for families and friends dealing with mental health problems.
  • Current approaches to help and restore mental health.
  • Goals and strategies for the individual families and friends.
  • What to do, and how to help someone in an acute mental health crisis.

Quotes (Tweetables):

“(Men) have a tendency to internalize and try to cope with their problems on their own rather than reaching out to connect with other people. Often those people would be their family members, friends or colleagues. When people, especially men, feel they need to do it all on their own and are suddenly totally overwhelmed.”

Mack Black, M.D.

“When we (as psychiatrists) talk amongst ourselves about preventing suicide, we don’t talk about if only we could see everybody out there, we could stop it… we talk about preventing access to means, dangerous means. We talk about how alcohol can set the stage for someone to become suicidal. We talk about access to guns; we talk about access to other weapons.”

Brian Poeschla, M.D.

Recommended Resources:

  • 211 in King County (WA) for a directory of mental health services
  • Online therapy
  • National Suicide Hotline 988 (available July 2022)

988 Suicide and Crisis Lifeline: 988 announcement PDF

Episode Transcript: 

Intro (00:07):

Baseball game, day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures, whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health, as presented by the Washington State Urology Society, to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body, after all it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body, if you know you should, but haven’t yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast, as we explore men’s health with renowned experts and embark on a journey towards better health!

Dr Richard Pelman (01:21):

On this episode of The Original Guide to Men’s Health, we’ll be delving further into mental health. We’ll be interviewing Dr. Mack Black MD, who is an assistant professor of psychiatry and behavioral medicine at the University of Washington School of Medicine. He’s an attending at Harborview Medical Center on the consulting psychiatric service. With him is Dr. Brian Poeschla, Dr. Poeschla, M D, is an associate professor of psychiatry and behavioral medicine at University of Washington School of Medicine, attending psychiatrist at Harborview Medical Center and Director of Intake and Brief Intervention Services, the psychiatric unit and a consulting psychiatrist. Well welcome Dr. Black and Dr. Poeschla. We have previously reviewed depression. We’ve reviewed a bit about suicide, but mental health encompasses so much more. I really wanted to do an additional episode to look at some of the things that you may be encountering. We had reviewed the potential to talking about anger management and why men get themselves in such trouble, some gun violence, anxieties. What are some of the things that you both see? You’re obviously here in a very acute setting with people who get here because they really are in need, but we also might explore just why people might want to see a psychiatrist who are doing pretty well, but have things that bother them, take it away. Where do you want to start?

Dr. Black and Dr. Poeschla (02:46):

Well, you’re right. Rich. We work in a very high acuity environment. So, we see some people that are in big trouble. I think one of the things that I want to make clear is that some of those people had no how quickly things could escalate. And I’ve seen some people who are family, men have kids and marriages and homes and careers, and they still kind of injure themselves very severely under the kind of the perfect storm of stressors. And I’m happy to try to illustrate some of those stories. I also work in another setting in the adult medicine clinic where, you know, we’re seeing more kind of day-to-day manifestations and trying to get people engaged into treatment that can be helpful for them. So, I’d like to share a little bit of those experiences as well as just what it, what it takes to, to cross that threshold, to meet with somebody, to start looking for some assistance.

(03:48):

I think Mack is right. We do see people who have become very ill. I must say, you know, we’ve seen a lot of people and heard a lot of stories, and nothing really can phase out in that way. But I would say that Mack, like getting help sooner rather than later with always a good thing.

Dr Pelman (04:05):

Yeah. Let’s go back to Dr. Black. You lead a scenario where things rapidly unwind for somebody. Is this something that, where somebody went through life and dealt with stress and everybody has various types of stress in their life, everybody’s busy or were there warning signs that somebody who’s going through stress management was difficult for them. I mean, if somebody here who all of a sudden had something just happened or was this sort of a life process, you know, somebody listening is going well, how does that happen? Take us back to somebody’s case going kind of through their life, a little bit to illustrate a case that’s kind of an amalgam of Fernanda visuals.

Dr. Black and Dr. Poeschla. (04:36):

So as to protect to their privacy, one kind of case that I’ve seen a number of times here in the acute care setting, where I’m working with surgeons and internists, had a very substantial stressor at work and combines that with some liability to alcohol overuse and a tendency to internalize and try to cope with their problems on their own, rather than reaching out to connect with other people. You know, often those people would be their family members, their colleagues, when people, especially men feel like they need to do it all on their own and suddenly are totally overwhelmed by a situation I’ve seen. Some people that have, you know, cut themselves in ways that they have a very hard time healing from a very scary situation for them to be in. And it’s a very scary thing for their families. I’ve seen some people that didn’t think that they were going to survive the injuries that they did in a moment of desperation. And, and then we help them to see like how to kind of put things back together again, on the other side of an event like that,

Dr Pelman  (05:56):

Besides themselves. What other ways might somebody present?

Dr. Black and Dr. Poeschla (06:00):

At Harborview? We have kind of a unique opportunity because this is a major trauma center. We see people from a multi-state region who have had pretty severe gunshot wounds. This is one of the only places where you can go to recover from that. If you need neurosurgery, for instance, a gunshot wound to the head is almost universally fatal, but we see that people who survived those injuries, we see people who’ve attempted to burn themselves to death. People never imagined they’re going to survive these sorts of things, but often, on the other side of it, you know, they, they don’t want to die anymore.

Dr. Poeschla (06:39):

This of course can give a kind of skewed picture of what it’s like to get mental health care because Mack works in a service where he’s helping surgeons or seeing people who have been previously injured. But we see people in the outpatient department who are suffering from barrier, seeing them died in depression, it’s abuse at all stages along the way. And so, the point is that I think people can get help and the sooner they do it, the better I would make a plea for anything, now while we’re on the subject of the way that people been injured in self greediest. But yet we often hear the idea that, well, if we only have enough psychiatrists out there, if we only had enough mental health professional doctors, in the community, get the people and ferret out all the mental illness and treat it quickly. Then we wouldn’t have to worry about people attempting suicide, not about having guns, not about having knives or access to weapons.

Dr Poeschla (07:34):

It’s about getting mental health care quickly. And while Mack and I, of course, being psychiatrists are all for the best mental health care and delivering it to as many people as possible. And in fact, our department specializes in services, research, and then ways to extend, psychiatric care to the most people possible at the same time, when we psychiatrist talk amongst ourselves about preventing suicide, we don’t talk about if only we could see everybody out there, we can stop it. We talk about preventing access to me to dangerous means. So, we talk about how alcohol can set the stage for someone to becoming suicidal, to act on these suicidal feelings. We talk about access to guns. We talk about access to other weapons. We talk about access to all the kinds of things people can use to harm themselves. I think that’s an important element to bring in here that we, psychiatrists do not have grandiose ideas that if we could just see everybody, we would know who would attempt suicide would get stopped. No, we talked sensibly about keeping guns out of the home and getting help early and seeing dangerous signals ahead of time. 

Dr Pelman (08:50):

If We could then look at some other issues that guys have, because time is not on our side here, anger management. When did guys step over the line? You know, what, happens to a guy who not necessarily anger towards himself, they may be angry at himself, but it’s displayed towards somebody else. Why does that happen?

Dr Black (09:12):

I think one, one way to frame that as, what is that person’s developmental experience been like? And, you know, people have a lot of what are called adverse childhood experiences in our business. That’s something that we regularly take inventory of, you know, experiences of being abused themselves as children, of witnessing violence around them and their families or their communities. You know, in some ways this is sort of the water that many people and men particularly just swim in throughout their life. And so, some of the ways to understand when men are violent toward other people or are just violent in general, is to put it in context of how they’ve been the recipient of violence themselves. 

Dr Poeschla (10:02):

If someone comes to me, who’s having trouble with anger, and we have various terms for this. For example, we have this term into critical intermittent explosive disorder, which really isn’t a diagnosis so much as a description masquerading and then explanation, and finally an explanation of anything. But it’s a description of something, a problem the person might have. But if someone comes to me, if a man comes to me with problems with anger, the framework I’m going to put that in is to say that people get into psychiatric trouble in ways that need to be looked at from four perspective. But Mack is talking really about what I would call life story perspective, what has happened to the person over a lifetime, and how that might, and what they’ve learned in that lifetime of lived experience, the things they’ve learned about how to handle conflict, how to handle anger.

(10:50):

So that would be one way of looking at it, but people get into trouble for other reasons, because of psychiatric diseases, kind of real problem in their brain, the mind that we would legitimately call disease such as bipolar disorder or depression, then that we can treat with medication and other treatment. But that it makes sense to try to cure people also get into trouble because of things that bearing not so much categorically like a disease, but because of their temperament, personality, and got buried on a continuum, these are personality traits that we all have. And it’s not that I have them and somebody else doesn’t, if that the person who’s in trouble with them has then to a degree that gets them in trouble, same trait that I might have, whether whatever they are, we all get angry at times, but that person might be prone to that kind of enduring trait. And then people get into trouble for things they’re doing to themselves. Behaviors. You know, we see over and over that alcohol drugs contribute to problems with anger management. So, to sum that up diseases, dimensional traits, behaviors, and you get a four-perspective view, you look at when we try to make sense of why a person having trouble with anger.

Dr Pelman (12:05):

Go a little bit into how you’re treating these people. We’re helping them see insight into their problem. We’re giving them a structure. We’re helping them develop some tools that you might use medications. And while a primary care doctor can prescribe antidepressants, a nurse practitioner might just use antidepressants, not the same medication works well for everybody. So, in the world of psychiatry, you kind of give us a little background into that.

Dr Poeschla (12:31):

Well, people have heard about antidepressants. Of course, they’ve heard about the medicines like Paxil, Prozac, Celexa. These are the things that you call selective serotonin reuptake inhibitors or SSRI’s. SSRI’s do many things. One of them, they deal with lifting mood and help people with depression, but they can also shift people down a temperament scale of what I would call neuroticism, shifting more tendency to strong negative emotion. We all have negative emotions at times. Some people have a tendency to have stronger feelings than others.  And medicines, like SSRI’s can mellow people, in plain English, shift people away from those strong feelings. And that can be helpful by itself. We also use medicines like lithium and Depakote.* They can help people who need the medicine to be used for bipolar disorder and also used for anger management. We use, you know, I feel we’ll use all of our medicines for everything. In some ways we make them and combine them in many ways. So, it really does depend on our work. And the doctor choosing one or two or three medicines in the context of that person’s whole constellation of pathology, but yeah, Mack, you have thoughts?

*This medication is used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder), and to prevent migraine headaches. It works by restoring the balance of certain natural substances (neurotransmitters) in the brain.

Dr. Black (13:49):

I think, like any other medical decision, these are all risk-benefit decisions. And we’re part of it, our responsibility is to choose treatments that are safe. And so, give people the best information possible about what sorts of side effects they might expect, or, you know, might need to endure to get some benefits. In the case of medicines, like Brian was mentioning the serotonin re-uptake inhibitors, you know, they’re very safe. So that that kind of calculation isn’t a difficult one. It’s more about, you know, is it worth taking a pill? So, if it can help over a period of weeks or so, some of our medicines are more difficult, especially for people that have other medical conditions. And so, I think that’s where having somebody who has our kind of experience with medication management can be particularly valuable and, you know, and those are the people that we end up seeing. We tend, you know, 90% of psychiatric medicines are prescribed by primary care doctors and other people essentially in a primary care role. (Like Nurse Practitioners) So we’re tending to see people with more resistant illnesses or multiple illnesses, major medical comorbidities with psychiatric illness.

Dr. Poeschla (15:18):

Having said that, I think Mack would agree that we see medicine as… for example, in anger management, they can be very useful and they do have a role, but we never see medicine as the only thing that we’re doing for the person. We try to avoid a kind of simplistic push-button-remedy approach for emotional troubles or the idea that the pill is for every problem in life. We certainly don’t believe that. And so, we always see anger management, which has been by definition, as a complex problem. And so, we always see if we are going to prescribe medicine, we see them at the adjunctive or part of the solution, but there are other things. So, for example, meditation, relaxation, cognitive behavioral psychotherapy, dialectical, behavioral psychotherapy, which otherwise known as DBT. Something, the University of Washington, has been very good at because they pioneered that DBT with the professor at the University of Washington, and I think we’ve gotten pretty good at doing DBT at Harborview in Washington. We have a lot of people who are quite expert at it.

Dr Pelman (16:24):

So, if there’s a listener and they’re being treated and don’t feel that they’re getting the results they want, they should know that perhaps different medication management might be useful to them along with what you’re talking about, which is going back and continuing to work. 

Dr Poeschla (16:41):

Yeah, in a synergistic way, these medication and psychotherapy come together. And one plus one is more than two. 

Dr Black (16:50):

And it can take time now, where there’s no way that we know in advance what may work for an individual. And so, a lot of people will say like, “I don’t want to be a guinea pig.” And I think that’s a great conversation starter of what it means to engage together and our purpose of finding an effective treatment and being open. We won’t know immediately. And it’s sometimes even after time has passed under the best of circumstances, it’s still hard to make an entirely objective decision. And sometimes people do need to try a few things before, you know, it’s likely that something will be helpful and that there are the medicines that have only this much of a role. So don’t distract yourself from the possibility of other kinds of interventions, like psychotherapy. Also work with couples, families as an important piece of that, because especially with anger, when once it’s a safe situation, usually helping somebody to work on more positive ways of communicating and helping build relationships that are helpful to them and supporting better function overall, you know, that that’s what’s going to help them to stay kind of recover from whatever has gone poorly to build some resilience in the longer term.

Dr. Pelman (18:15):

So again, going back to an individual who may be listening to this, who’s maybe having a tough time at work right now, or some other family crisis, perhaps it’s a family member and things are not going well or a relationship that’s not going well. It seems as if there are warning signs that that person might want to know about, that’s going to keep them from escalating to alcohol or trying to cover their problems, or where could you intercede before somebody gets to that point where they’re trying to harm themselves? 

Dr Black (18:45):

What, one of the biggest warning signs that kind of runs away from people quickly is if they’re having trouble sleeping, that’s kind of a common factor. And for so much of health in general. It tends to destabilize any mental health condition and/or create sort of new mental health problems. So that would be a clearer threshold for looking for help. Another thing just on the subject of how, like what, what could be on the menu in addition to not having, you know, dangerous things around and not using substances to cope with stress would be that there’s an epidemic of loneliness in our country. And a lot of the people we see, they don’t have anybody to turn to. We ask people, you know, who can we call that, you know, might be able to help you out or can tell us a bit about you.

(19:39):

And a lot of our patients say there’s nobody. And so, building some sort of safety net of social connections, I think is a key thing that is kind of a foundation of mental health. Just ways to, even if you have a friend, you can talk to her about some things, can you talk to them about a real crisis? Could you talk to your spouse about a real crisis? Could you talk to your coworker about a real crisis? And often you need more than a few people to have a robust network.

Dr Pelman (20:11):

Not isolating yourself and not turning to substances would be a way to help turn a direction that could escalate into self-harm. Somebody says, “I just don’t have anybody,” in our prior episodes with mental health, we spoke about the availability of crisis clinics and hotlines. If somebody feels that things are escalating, go to a clinic.

Dr Poeschla (20:33):

My barrier is calling today available at Harborview, we have outpatient services to be able to pull away the addiction and mental health services. People can call the hotline quite a new hotline. And so yes, there are plenty of services available at Harborview.

Dr Pelman (20:50):

That’d be for somebody who has a crisis. If they can build a support network, not become isolated that can help just manage issues of life. Do you see people after they’ve been here who are then able to construct support groups and support structures for themselves in their lives, or if somebody who’s coming down this path has a personality where it’s just very difficult for them to do that?

Dr Black (21:13):

I think we see people in both of those groups. I think the first category of people who can build support structures often they’ve chosen often out of shame. They’ve chosen to isolate themselves about specific problems or they’re spending all of their energy kind of keeping up with a false identity. You know, it was, it was competent and, you know, still meeting all of those masculine ideals that our culture enforces and being able to talk to the people that they could rely on for some support and allow themselves to have some vulnerability and acknowledge, like “I can’t do this alone.” Usually that’s something that can happen in terms of, you know, the time that we’re seeing them in the hospital setting. And I think that often it is kind of a key factor in somebody’s ability to create some safety resources and get through a crisis. And usually, they feel tremendous relief in doing so. 

Speaker 2 (22:16):

So, you might in intervention help somebody acquire a skillset, or the tools, to be able to help build that network.

Speaker 4 (22:24):

Certainly, we rely not just on the person coming to us, but the patient’s loved ones, people who know them well, helping us to fill in the gaps and we take it. So, when a person comes to me and I’m going to try to figure out how they got into trouble, and how I can help them get out of it, we take a vote. And what does that involve, that involves a family history of mental illness, and involve the personal and social history which I’m interested in. We want to understand the person until you their entire life and kind of put together the trouble, the experiencing from a bot in a bottom up way, instead of simply a top down way, a checklist of symptoms, we ask it cheaper, she’ll check with symptoms and try to fit that into a DSM* framework, which would be kind of a top down way of looking at a rather, we’re going to build up from the bottom up, how mental, how their difficulty emerged from the fabric of their life and the difficulties encountered over the lifetime.

*DSM stands for “Diagnostic and Statistical Manual for Mental Disorders.” It is the manual published by the American Psychiatric Association which lists all classifications of mental disorders. The organizing concept of the DSM is to assign symptoms to the classification for which they are most relevant.

Dr Pelman (23:33):

So, you, in essence, by delving into the past help somebody perhaps see into their structure, mental health from their background, from their prior experiences where they can help make corrections once they recognize some of these issues.

Dr Black (23:51):

That’s a really well put summary. Yeah. I think patients that whom we go through this process, you know, which takes a long time. I mean, this is at least an hour-long process, and often it occurs over multiple visits. I think people find that really affirming that we’re really working to understand who they are, and they often haven’t had a relationship like that before with the doctor. And I think that that’s often a misunderstanding about what psychiatrists do as if, you know, maybe we can read their minds and somehow intuit something that they’re trying to keep hidden from us to do something they won’t want or invade their privacy. Whereas we’re really trying to, to earn their trust and be invited into some of the most difficult things that they’re experiencing, going through.

Dr Pelman (24:41):

True psychiatric underlying conditions, not head injury, but bipolar disorder schizophrenia. These things aren’t always evident from birth. Generally. This is something that arises in development at some point through somebody having a very odd behavior.

Dr Black (25:02):

Yeah. One of the things that is kind of not entirely unique, but I think Harborview specializes in, is treatment of people in their first episode of one of those more severe mental illnesses. And I think that’s one of the most challenging and also rewarding kinds of hospital-based procedures that we do. It really brings together all of this formulation, you know, getting a deep history, understanding how often it’s a family unit that we’re treating, you know, helping the parents to understand what their child is going through, how to communicate with them through this process where everybody is terrified. And often, you know, often it’s the police have been involved or there’s been some sort of dangerous situation that’s precipitated a hospital stay. And then, you know, but if we can get it right, if we can help somebody to see that there’s a role for treatment and to stay engaged, once they leave the hospital and to have some kind of safety procedures that the family and the patient can put into place so that when inevitably something stressful comes up, they can kind of rebalance and stay engaged.

Dr Black (26:19):

I think that’s one of the most rewarding things that I get to do here.

Dr Poeschla (26:23):

We want families involved. We really do like the family, the old-fashioned idea that the person would see a psychiatrist and it would take place in complete isolation. The kind of “confessional booth” way. And no one else involved. I think we’ve gotten beyond that. Lots of psychiatric conditions do declare themselves in childhood developmental disorders like autism, but depression, substance abuse these we do see. We have a whole field called child psychiatry that deals with all the problems that include bipolar disorder, mood disorders, etc. these things can develop in childhood, of course, but they can emerge suddenly, or suddenly in young adults too. And that can be a difficult childhood development.  All the way to college and suddenly develops difficulties, he or she never had before. And that’s the top thing that we want to work with them.

Dr Pelman (27:22):

We see aging and I know geriatric psychiatry is yet another branch. And I don’t know if you want to go into a little background, but as people age behavior changes and they’re become challenges, some of its cognitive, some of it’s not, but if a listener has a family member that goes  “gee dad isn’t doing as well as he used to,” or “mom’s not doing as well, or my older brother isn’t doing as well, or my neighbor, who’s getting old.” You want to talk a little bit about what happens in life. Spectrum from the senior side.

Dr Poeschla (27:55):

The best science is showing us that brain health and cognitive health has everything to do with our basic medical health and heart health. Basically, good heart health is crucial to good brain health, eating well, keeping away 90 new sugar-laden foods, taking care of our cholesterol exercise, all of these things are high blood pressure, keeping my blood pressure under control. If just a few basic things, if you’re smoking cigarettes, stop smoking and get the blood pressure under control, would be like two massive things, the simplest things, that you can do to make yourself a healthier person,

Dr Black (28:36):

Being a consultative psychiatrist and having a foot in medicine and psychiatry. What are some of the medicines that people should not be taking? What can we sort of pair away? Sedatives? A lot of sleep medicines are not safe past age, 60 or so. And there’s a very long list of what are called the anticholinergic medicines. Things like Benadryl, a lot of over-the-counter medicines contain anti-cholinergic drugs as well as many prescriptions.

Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study – PubMed (nih.gov)

Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study | Dementia and Cognitive Impairment | JAMA Internal Medicine | JAMA Network

Speaker 4 (29:08):

Yes. We now know that the anti-cholinergic medicines like Benadryl increase the risk for dementia. And so, with older people in general, as you know, we tend to collect medicines as we go through life. And the main thing, the country, how many medicines you can collect, you don’t watch it very often. You know, a person might be on 3, 4, 5, 6 to 10 medicines. Then when they were 40 years old, that was fine when they were 15 is okay. But then when they hit 60 or 70, it starts to not be okay. And the same medication load is causing problems cognitively. And otherwise, it can be making them depressed. It could be making them confused so that they can develop what we call delirium, because the same medicine that worked just finally a younger are not working at all now. And so, it is true. When I see an older person, one of their first tasks, I have some time just to clean up the, there are too many medicines they’d collected over their lifetime. And that often goes a long way for them helping the person and getting rid of unnecessary medicine.

Dr Pelman (30:11):

Let’s just go for a moment, to a patient who’s, or just somebody listening who’s, doing fairly well, but maybe not being so successful in relationships or having trouble with jobs, or, you know, they’re not happy with their quote “life” in the sense it’s not severe. They’re not thinking of harming themselves. The things just aren’t working out. Is there a role for a mental health professionals just to help somebody sort their way through life’s path?

Dr Black and Dr Poeschla (30:41):

Of course. I mean, when we say the term mental health professional, any kind of mental health professionals, psychiatrists, psychologists, social workers, we have here at our review, we have people we call case managers to help people navigate our kind of perversely complicated healthcare system these days. So, yes, I think one of the ways we help people the most, if I worked in, you’re putting specialists working together. So, case managers working with the psychiatrist to kind of just working with psychotherapists one can find a clinic where one can see both the doctor and, and a case manager or social worker. This can all be very helpful to work with a group.

 (31:22):

One of the things that I think I often find myself referring people to in Harborview Adult Medicine system, which is our primary care or one of our primary care clinics here, is called the Behavioral Health Integration Program, which is basically two full-time social workers who are trained as psychotherapists and embedded within that clinic, basically to decrease the threshold for people to see somebody for counseling. And most of what they do is really kind of helping people to navigate some of these kinds of usual problems, more effectively to provide some support, to help them kind of get over some obstacles, learn some skills. And usually, it’s a time limited engagement. So psychiatric

Dr Pelman (32:14):

Intervention isn’t necessarily always psychotherapy. No, somebody who’s specializing in psychotherapy. Just go through a little background for the listener. What is psychotherapy? I mean, how is that different from seeing a psychiatrist?

Dr Black (32:28):

It’s often not somebody who’s trained as a psychiatrist. That’s probably the first thing. So, there’s a lot more psychotherapists in the world than there are physicians. Psychiatrists. The focus, as Brian said, is usually on some sort of problematic behavior or thought process.

Dr. Poeschla (32:49):

I think there’s good that that things like cognitive behavioral psychotherapy and exercise, by the way, it can be as effective, or more effective than medications, for some people. And sometimes it’s the combination of an antidepressant and exercise and psychotherapy that can turn things around for a person, cognitive behavioral therapy. A pioneer in cognitive behavioral therapy Aaron Beck, not a long time ago that help people feel better. You had to help them to think differently about their lives. So changing feeling involved, helping people to cognitively restructure. What held Beck back called the automatic thoughts that had kind of automatic negative assumptions. They had about themselves, about the failures, about the connections they were making. And so, the essence of that is to help people, we structure the assumption they have. And once you change the way they think about things, you help them feel better and deal the old idea with let’s just talk about your field, DBT, the idea to get people, to look at how the assumptions they have and change with it

Dr Black (34:02):

And practice doing things that reinforce a different set of assumptions and the way they think and a feedback pattern.

Dr Poeschla (34:10):

Feedback, the negative assumptions they have and the feelings they have and the cascade that feeling they have. And that leads to more negative assumption. And so, a good psychotherapy can help a patient take a step back from that. Look at that and change it. I will say exercise. If I could get more people to just exercise, just walk 40 minutes twice a day, and nothing fancy, nothing expensive, but just get them to get off the couch and get out and exercise, get out in the sunshine. That will go a long way. In fact, there are a lot of data that shows that exercise can be as effective an antidepressant as you know, medicine, any of our medicines, I throw medicine darn good too, but the only part of the picture.

Dr Pelman (34:52):

And every episode, I think I could go back and listen to probably every specialist refer back to diet and exercise as being important. And so here we are in mental health, and it goes back to diet and exercise. We emphasize exercise but imagine having a good diet also helps your brain.

Dr Black (35:07):

I’d also like to point out sleep is another huge one for mental health again, and sleep is one of the things that a variety of cognitive behavioral therapy is best at. One of the very most effective psychotherapeutic interventions in psychiatry is CBT for insomnia, basically challenging some of people’s negative assumptions about sleep or not really about insomnia, how they’re not going to sleep and setting up some very specific kinds of day by day or week by week goals about when they go to bed, you know what they do if they can’t sleep when they wake up,

Dr Poeschla (35:43):

Up, the term around here is sleep hygiene, that kind of old fashioned, I guess, but it’s a good term. And it really does mean, you know, look at cleaning up one’s act in terms of that one sleep habit.

Dr Black (35:56):

It can be a real slippery slope for people to be seeking out medications that accumulate harms in pursuit of sleep. And then sometimes, you know, looking at medicines and focusing on insomnia can distract people from looking at some real important and treatable medical conditions.

Dr Pelman (36:14):

Any other thoughts you have or resources for people as we kind of move to closure here?

Dr Black (36:21):

I know in King County you can dial 2-1,-1 to get some directory including mental health services. Another thing I’d add I’m just because we’re probably talking to people who, you know, may or may not have that severity of concerns and might benefit from some more accessible and also less expensive interventions. There’s a tremendous and fairly new architecture for online cognitive behavioral therapy, where you can work with a therapist that could be anywhere. You get practical support. A lot of these are all even self-guided modules and some of them have good evidence that they’re equal to those delivered by clinicians. And you know, many of them are much reduced costs and you know, it’s effort dependent, of course, and there’s no substitute in some circumstances to be working with another person. That’s something that you can’t really recreate otherwise, but if somebody wants treatment and that’s a good fit, it’s certainly much more accessible.

Free Online CBT Workbook (cogbtherapy.com)

Dr Pelman (37:32):

I appreciate both of you giving us your time, your knowledge and hope that if somebody is listening, if they are feeling that they are not quite where they want to be, that they take advantage of some of your advice. So thank you both very much. Thank you for having me.

Dr Pelman :

This completes another podcast chapter of the Washington State Urology Societies: “The Original Guide to Men’s Health.” This is Dr. Richard Pelman reminding you to take care of yourself. The Washington State Urology Society wishes to thank all contributors, who volunteered their time and knowledge. The information presented is the opinion of the speakers. The Society also wishes to thank Sean Fox for his invaluable technical assistance, music theme “San Juan bells” written and performed by Dr. Dave Whiting, the podcast is the property of the Washington State Urology Society.  Reproduction and use without the express consent of the Society is strictly prohibited. For more information about men’s health visit wsus.org or visit your physician or care provider.

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