Therapy Insights: Treating Depression & Anxiety with Julie Isaacs, LCSW
The Intersection of Depression, Anxiety, and Trauma
Depression and anxiety disorders are different mental health conditions that can have similar symptoms and can even co-occur. However, they have different causes that often require different types of treatment.
Julie Isaacs, SVP of Operations & Therapy at Heading, offered her insight into how depression and anxiety disorders intersect and the role of specializing a therapy practice to address long-standing and extreme stress.
Related Yet Distinct Diagnoses
“Anxiety and depression are like first cousins; they relate very well to one another and often share a lot of similarities. That said, the experience of depression, anxiety, or post-traumatic stress disorder (PTSD) is also unique to the individual person, and the therapeutic tool kit should be personalized as well,” shares Julie Isaacs.
Diagnostic criteria for mental health disorders are helpful for research and developing treatments and support, but like other aspects of health problems often coexist. Depression is considered as a mood disorder and is often characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities. Anxiety disorders are conditions that include excessive and persistent feelings of worry or dread, and typically comes with edginess, difficulty concentrating, fatigue, increased muscle tension and discomfort in the body, and trouble sleeping. Trauma is a criterion of PTSD and the result is a response or set of responses to a deeply distressing or disturbing event, such as a natural disaster, a car accident, or a violent crime. People who have experienced trauma that results in PTSD experience anxiety and fear, may have flashbacks and nightmares, and become hypervigilant to situations that remind them of the event or carry a perceived threat. Avoidance of uncontrollable situations and hypervigilance are coping mechanisms that promote personal safety. However, they often snowball into more rigid and isolated ways of being. Over time, this increase in rigidity and isolation, along with the fear, anxiety, flashbacks, and nightmares, can leave those with PTSD at risk of developing depression as well as a substance abuse disorder.
While PTSD can cause depression, depression is less likely to have been brought on by a single traumatic event. Instead, depression’s causes are more varied. It might be set off by a stressful life event that gives rise to sadness with a life of its own. Evidence suggests there may also be biological triggers that can put the condition in motion even in the absence of difficult circumstances. Often, it’s a more complicated combination of factors.
“Depression is sometimes experienced as ‘anger turned inward’, and this anger is also experienced with anxiety disorders and PTSD especially if a person has gone untreated or undertreated for a long time,’” shares Julie.
Julie has dedicated her career to the treatment of severe depression and anxiety disorders. Through her years of experience working with individuals struggling with these mental health disorders, she has gained unique insights into the best approaches to helping people find healing and improve their quality of life. She also has vast experience mentoring therapists who want to specialize in these areas and knows firsthand how rewarding and challenging the work can be.
Understanding both the intersection of symptoms, and causes are important for appropriate care. However, the skill of understanding what someone is going through is not only a science but also an art as every individual’s personal experience of their mental health is expressed differently.
Naming the Unspoken Symptoms of Mental Illness
While diagnosis is essential for many aspects of treatment, it can come with strong feelings of shame due to the stigma associated with having a mental health condition.
“Overcoming shame is a big part of developing the courage to seek treatment, and a therapist needs to know how to not only ask the right questions or identify the right symptoms but also how to build trust and rapport,” Julie points out. “Some patients might tell you right away what they’re going through. But it’s also very common to have a patient who is reluctant to use the words ‘depression’ or ‘PTSD.’ And that could be for many reasons. They may feel it will threaten their job, their standing, or their personal identity.”
As such diagnostic labels, while necessary and valuable for many medical and therapeutic reasons, carry substantial weight for the individual, which should be seriously considered.
Julie also noted that stigma can have a different impact on men and women, especially when it comes to how they express their symptoms and whether they seek treatment.
“Men struggling with severe depression or anxiety often seem ‘functional’ by going to work and doing their best to appear ok outside of the home, but when they come home there is often a big shift in their behavior and they might shut down. Men are also more often slow to seek treatment. Women on the other hand are more likely to pull the covers over their head and have a hard time leaving the house, but are more likely to feel comfortable seeking treatment. We have to break through gendered conditioning to really address the heart of the matter – no matter the gender expression or societal norms – all people should feel comfortable seeking help.”
Unlike a broken bone there’s no x-ray for depression or anxiety. Through experience and training therapists build the skills to hear what’s going on even if a patient has a hard time talking about it. While people may not come right out and say, ‘I have major depression’ or ‘I have PTSD’, they might say other things that indicate they are struggling. For example, they might say ‘I’m not sleeping,’ ‘I’m having trouble thinking’ ‘No matter what I do, I just don’t feel like myself,’ or ‘I experienced X and just can’t stop thinking about it.’ While it’s gotten better, there’s still certainly shame and stigma around getting help, especially among men, in certain cultures and social circles, and among those with jobs where they need to be perceived as extremely competent or feel a diagnosis could jeopardize their employment.
According to one study, 29 percent of male participants said the reason they haven’t spoken to anyone about their mental health is because they are too embarrassed to speak about it.
Forty percent of men in the study said it would take thoughts of self-harm or suicide to get them to seek help.
Shame will take many different forms depending on the individual, their background, and their lived experience. Shame often comes with feelings of isolation, failure, and embarrassment. In a traumatic event, or repeated traumatic events, there can be significant fear and shame associated with it as well and which can spur negative thoughts about one’s self. Similarly, with major depression, one might feel guilt or disappointment for not being able to deal with the symptoms ‘on their own’ are common. Trained therapists and psychiatrists are able to help their patients identify these thought patterns in themselves, and dismantle their strong grip.
Addressing the Whole Person in Therapy
Over years of treating patients, Julie notes that, in addition to common mental symptoms, there are also common physical symptoms of both depression and anxiety disorders.
“To be honest, no one is sleeping,” notes Julie. “When we’re dealing with a major mental illness, we’re either sleeping too much with low-quality sleep, or we’re not sleeping enough. But, in truth, no one is rested. And there’s only so much you can do when your body is exhausted. Therapists need to be curious about what’s going on in someone’s body and not just their mind and emotions; depression and anxiety don’t simply exist from the neck up.”
The conversation about mental health is becoming less and less siloed from other aspects of health. Mental illness has a strong physical component. Both anxiety and depression can involve changes in appetite, sleep, and energy levels, as well as difficulty concentrating. Studies show that mental illness can even impact our immune systems and cause or exacerbate other physical conditions such as heart failure, high blood pressure, and cancer.
As such, many people benefit from a holistic approach to healing that includes biological and lifestyle interventions, mindfulness practices, and regular exercise. Additionally, more and more the field of psychiatry is also turning towards interventional treatments like ketamine, and psychedelic research, to address the neural pathways within the brain in ways that traditionally prescribed medications do not.
Comprehensive treatment is often needed when depression, anxiety, and PTSD become severe or recurrent. When this happens, it’s particularly helpful to have a team that is highly trained in these specific disorders to deliver personalized treatment.
Improving Therapy & Mental Health Outcomes
The shortage of mental health care providers in the U.S. is a known problem, with a recent survey indicating that 60% of psychologists are unable to take on new clients. Many states, such as Texas, are also short on psychiatric staff in hospitals and centers.
What is less talked about is what this means to mental health of providers, especially those treating patients with severe depression and anxiety. “The stakes are high. And among therapists, burnout is real,” shares Julie. “While it can be an issue for all therapists and providers, those focusing on more severe cases of depression and anxiety may be more likely to experience it.”
Her remarks are well-backed up by recent studies. One report found that 50 percent of behavioral health providers reported feeling burnout out, and that a lack of training was a common source of stress. The consequences for those with severe mental health conditions can be devastating.
“Undertreated mental health struggles can absolutely be lethal,” shares Julie, underscoring the importance of proper staff and adequate training. To address the issue, Julie says we should focus on education. “Providers dealing with more severe cases need access to continued education as well as personal support through supervisors, mentors, and peer groups.”
Other mental health professionals feel the same. When discussing the problem of mental health care in rural Texas, Dr. Steve Bain, founding director of the Institute for Rural Mental Health Initiatives, also highlighted the importance of training.
“Knowing the patterns among diagnoses certainly helps a therapist connect the dots within their patient’s experience, but it’s also important not to jump to conclusions. This is where peer support, continued education, and mentorship relationships within the field can be incredibly helpful. We can’t practice in a vacuum. Making the effort to continue our own education and develop a network of peers and mentors who challenge our thinking improves the quality of care,” notes Julie.
“And like in any profession there may be a time when it is helpful to niche ourselves diving deeply into a few disorders to develop the level of quality and experience a patient with severe struggles needs. That can be challenging and it takes time. But I do know that therapists who are willing to go the distance in their education and experience to support severe mental illness can truly save lives.”
Hope For The Future of Mental Health Care
Despite the prevalence of depression, anxiety, and PTSD the diagnoses themselves can come with a strong degree of stigma. But as the conversation around mental health continues to make its way out of the shadows and into the mainstream, more people will feel ready to seek help.
Julie notes that things are moving in the right direction, “I’ve witnessed a huge shift in the conversation around mental health since I first started as a therapist. Big picture, the fact that more people are talking about mental health is promising. Insurance plans, and employers are also starting to take mental health more seriously which is absolutely needed.”
“But, we also have a shortage of mental health care providers nationwide. Caring for people who have severe or longstanding mental illness is a demanding job. Providers need training, support, and resources that allow them to their job effectively, and their patients need access to a dynamic tool kit for care for better outcomes. The future of Mental Health will require tearing down silos around treatment modalities, continuing to embrace technology for improved access and education, and for the medical system to take mental health as seriously as physical health. Change has started and I’m hopeful we’ll get there” Julie concludes.
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