Dr. Grammer: “for some people, psychological ignorance may be bliss. And they may be completely content with the things they do in life. And they don’t need to think too much about their underlying motivations or the way they perceive things, when they go do something that they enjoy, they enjoy it, when they’re exposed to something they don’t enjoy, they don’t enjoy it. And that’s just the way the world is. And it’s a mistake for a therapist then to potentially go in there and start unroofing a bunch of stuff that is adequately defended, compartmentalized and being contended with in the way that that patient needs.”

[Life to Live by Grace Mesa (Instrumental Version) begins]

Beyond Depressed is a mental health podcast for people who want to know the science behind emerging treatments and if those treatments are right for them or a loved one. New therapies using psilocybin, magnetic stimulation, ketamine and medical marijuana are bringing people much needed relief. Together, we’ll take a deep dive into depression and how therapy, medications and drugs can help you feel better.

Beyond Depressed is hosted by Dr Geoffrey Grammer. Dr. Grammer is a decorated retired Colonel with the United States Army and is currently serving as the Chief Medical Officer for Greenbrook TMS. He has experience in psychiatry, internal medicine, and behavior neurology.

Disclaimer: The following podcast is for information and educational purposes only and should not be considered official medical advice.

[Life to Live by Grace Mesa (Instrumental Version) ends]

Dr. Grammer 

Welcome back to the podcast. My name is Dr. Geoffrey Grammer, this is Beyond Depressed, and I am joined again by my co-host, friend and professional podcaster, Joe.

Joe Clements 

It is good to be here. What are we talking about on this episode, Dr. Grammer?

Dr. Grammer 

So Joe, we’re going to talk about therapy, okay. And I think the question that listeners need to ask is, how do you know if you’re getting the right type of therapy for your specific concerns?

Joe Clements 

So one of the things I’ve noticed following in my job, a lot of different niches and subcultures is, as we talked about in the What is Depression episode, people status signaling over mental health things in a weird way. I’ve also noticed people becoming more and more specific in describing the types of therapy they’re getting as talk therapy is becoming destigmatized. I mean, you can name three apps that just offer it at the push of a button now, people are becoming more and more discerning over what type of talk therapy product they’re buying. Now, me personally, I don’t really know the difference between any of them, like in my head, it’s still like Freudian. You sit on the comfortable little couch and talk, but where should someone start? This is two questions, like one, where should someone start when thinking about talk therapy? What are the different types? And then the second thing is, who does it tend to work well for and who’s it tend to not work well for? Because I think one of the things people are going to be surprised by is how often it doesn’t work for people with major depressive disorder. But let’s start at the types like, what are the types? What’s on the market?

Dr. Grammer 

Well, if it’s okay, let’s go back and figure out how we even got to this idea of therapy. Okay, because it’s a relatively new concept. More than 120 years ago, the idea that you could treat psychiatric symptoms by talking to somebody hadn’t even been developed yet. So people have probably heard the term asylum. And that was essentially a psychiatric hospital, you know, in the 1800s. But the term asylum has its root in this idea of housing people, not treating people but sort of housing people and had more to do with taking those with serious psychiatric symptoms off the street now to public eye, then actually the altruistic notion of getting a better, and a lot of the horrors of psychiatry kind of came out of that this idea that people were in cages, which actually happened,

Joe Clements 

This is the concept of like, the haunted asylum that every town has.

Dr. Grammer 

Exactly.

Joe Clements 

Even from a good town if it doesn’t have haunted asylum nearby is what I would ask you.

Dr. Grammer 

Yeah. So you know, that combines two things, right. The some of the psychiatry unfortunately, still has this stigma in some places associated with it. And again, a couple 100 years ago, some people thought that psychiatric symptoms were more demonic possession. So that is frightening for people that believes that perhaps people are acting this way, because they have demonic infusion in them.

Joe Clements 

Okay. And so then just kind of storing people in this place where they’re treated in subhuman conditions just adds to the idea that this is a dark thing, that it’s something that is has to be hidden away. It’s something that’s possibly evil.

Dr. Grammer 

Well, and and it was pretty dark. I mean, make no mistake about it. Anytime you have a situation where you have those that have absolute control over others, right, it breeds maltreatment, you have to put in a lot of guardrails in place to keep that from happening. Okay. So if you look back, I mean, we literally used to put people in cages, where they couldn’t sit up, they couldn’t rollover, keep them from hurting themselves, keep them from hurting other people. There was a thing called a Benjamin Rush chair, where if you got real upset, they would kind of strap you to this chair and it had a little hole in the bottom that you could go to the bathroom through, they would blind you, you would have all your limbs kind of on the armrest and the legs of the chair so you couldn’t move or we would wrap people in cold blankets and get them slightly hypothermic. And each one of these things sort of had theories behind him. It wasn’t like someone was just hoping to, you know, be a sadist. Right but it so the intentions may have been good, but looking back upon it now it seems truly horrific. Eventually, there was a guy by the name of Pinel, who was like release the chains and start treating people with kindness, right. And so then was born out this idea of a Victorian environment of beautiful gardening grounds of these psychiatric institutions and so forth and classic music playing in the background. The idea is if you bring in culture and organization and altruism into an environment that that can help people get better. And indeed, just making that step did improve the symptoms of some patients, allowing them to be discharged just treating them with sort of an organized compassion, if you will. And then Freud came along and was like, well, maybe some psychiatric symptoms are related to our brains not navigating things that we think or experience in a way that can be resolved. And so we create symptoms to essentially resolve the issue. Okay? So that kind of was the beginning of this idea of bringing the unconscious outside of our awareness into the conscious mind. So therefore, then we can become more in control of how to work our way through those issues.

Joe Clements 

So what’s interesting that is to us right now, that is such an intuitive way to look at the human mind that Freud was the inventor of that idea. He was the first person to realize that could be how the human mind works. Why is it it took so long to get to the point where, because so much of Freud’s work seems to be based on this the same with young right, based on this idea of narrative, almost like the concept of story narrative goes back time immemorial in human history. Why does it take so long for that to become individualized?

Dr. Grammer 

Yeah, I think it’s, and we talked about this, in the first episode, this idea of sort of self determinism, right? And we would like the world to be, I think, some people, I should say, We’d like the world to be very cause and effect, good things happen to people who do the right things, bad things happen to people who do the wrong things, right. And we also want the security to believe and feel like our existence, our self awareness is part of some greater purpose. And when your ability to sort of feel well is outside of your control, it begins to challenge those more concrete notions. And I think people are understandably reluctant to kind of surrender to the true vulnerability that exists within our own awareness. And to acknowledge that we may not have I mean, we talked about do you feel in control, we actually may not have control over how we think and feel. And that can be really scary for some people to admit. And so I think therapy was slow to kind of warm, because in doing that, you sort of have to surrender to the notion that you may need something more than just yourself to get better.

Joe Clements 

So the idea prior to that would have been like it was either you are so far gone. And so far hopeless, the only thing that can be done is kind of a story way in a place where you can’t hurt yourself or others. Or you could just will yourself into being well, you could just correct your thoughts, change your behaviors and be fine. And Freud’s the first person, like there’s actually a middle ground here and the middle ground is if you understood what’s at the root of your bad behavior, you can then go back and integrate that issue into your thought process and become I don’t remember what the word he used for like full, or maybe it was just integrated. But you could become a whole and fully present person.

Dr. Grammer 

Yeah. And this idea of exactly like being fully integrated, or more commonly now, sort of self actualized, if you’re looking at the sort of hierarchy of needs here. And just to put this in perspective, right. So I did 25 years in the military. And I did two deployments to Iraq, and one to Afghanistan. And when I was in Afghanistan, I had interactions with other medical assets in Afghanistan, essentially, Afghan psychiatrists, right, and I was reading some of their literature on how they treat things like opioid addiction, okay. And there was a paper and this this was actually like written like a journal article, where the theory was that opioid addiction is born out of a lack of connection to God. So, and again, their religion for some people is extremely important, this idea of having this connection to God. So then they came up with this theory, well, if we reestablish the connection with God, people won’t want to use opioids. So that the way that they did that, and gets back to how you can do really terrible things with the best of intentions, the way they did that was they would chain people to a rock outdoors, with little to no sort of clothing, no shelter and just a minimum of food and water for days and days and days. And the idea was that you have, you’ve removed all distractions from your connection to God to reestablish that and someone goes through withdrawal and has your sort of environmental exposure in that sort of being in the outdoors without food, you know, adequate housing and shelter, and clothing, excuse me. And lo behold, they were actually these testimonials in its article about oh, thank you so much for doing this. I feel so much better, you know, because they just went through like seven days of like, horrible opiate withdrawal and, and heat exposure and stuff like that. And so, I think getting back to this idea of like, it gets a lot scarier when someone says, Well, maybe this isn’t just God, right? Maybe this isn’t as simple as this all or none phenomenon or idea of how mental illness occurs. So we’ve gotten more and more sophisticated over time to begin to acknowledge their different contributions to someone developing psychiatric symptoms. Therefore, we need different forms of therapy to help with that it’s one size does not fit all. And so one of the biggest things I want listeners to take away from this is, when you go see a therapist, it is completely appropriate to ask, what kind of therapy are we going to be doing? And why? Why this kind of therapy? And if you can’t get an adequate answer for that, that would make me very suspicious of whether or not that therapist was a good fit for my unique needs.

Joe Clements 

So what are the different types of therapy and common practice now? Because my understanding is Freudian therapy, the way we think of it isn’t actually really used. For the most elements of it are incorporated, but it’s not, you know, the same thing it was in 1890.

Dr. Grammer 

Yeah, I mean, Freud is kind of interesting. And I’m not a psychoanalyst, a psychoanalyst is sort of a disciple of the Freud and Neo Freudian movements, you have to go through very specific analytic training, you have to get your own analysis as part of that process. That’s not me. So as I get ready to, you know, support the idea of Freud, I want people to realize that it’s coming from someone who’s not on the spectrum of sort of devotion to that school thought, but actually, Sigmund Freud was a pretty, pretty smart dude, to be honest, he was a neurologist. And he developed all kinds of theories associated with essentially unsolvable unconscious conflict, leading to symptoms, and then developed a method of essentially pooling that unconscious conflict into conscious mind where then it could be navigated, along with factoring in the relationship that occurs between the patient and the therapist, as well as the therapist and the patient. How that gets used in promoting this is very labor intensive, it was often like five days a week, it’d be an hour at a time, he would sit on a couch and you know, at times would free associate to sort of began to bring these hints of this unconscious stuff up into the conscious mind. And then the therapist would begin to start making interpretations that were coalescent into more general themes that that the patient will become aware of. It was expensive, labor intensive, it was hard to scale to meet everyone that needed it, but it was where we started. So Freud definitely gets bastardized, I think, in late culture, and some people, some of this early childhood development stuff gets overly sexualized and misunderstood. So for listeners out there, Freud is a bit dated now, okay, there are some people that still definitely benefit from psychoanalysis. But what some people may have heard about, that doesn’t capture the full complexity of the work he had done. But at least he got us in this idea of, hey, what happens if I talk to people and help them navigate through some of this stuff? Can it help? And the answer is yes. Okay. So we’ve moved into different forms of therapy now. And unfortunately, the world of medicine. It’s unfortunate, unfortunate, the world of medicine has moved to this idea of trying to prove that everything is evidence based, that we can do a study and control other variables to show that the intervention itself is effective. Well, that gets harder to do in therapy, it is hard to do like a placebo for therapy, if you will, right. So as people will say, well, there’s no evidence that therapy works. Well. It’s not quite that simple. You can’t take half of people and have them sit on a couch five days a week and free associate and have that be a sham. Like I guess you could hire people off the street that know nothing about psychiatry to be the therapist and put them in like a bow tie and call it a day.

Joe Clements 

But which weirdly enough could still show some effects. Right?

Dr. Grammer 

Exactly.

Joe Clements 

Just because the patient is probably talking to someone that they trust.

Dr. Grammer 

That’s exactly right, there is something to be said about just the therapeutic advantage of feeling a sense of connectedness to someone. So as you look at these things, realize that some of the most evidence based forms of therapy are actually more concrete, meaning they’re very kind of circumscribe their manual base, they, here’s how you do it. Here are the charts that you fill out. Here’s what it means. And in some ways, I think it dilutes out all the different complexities that go into what makes therapy effective. So my point is take evidence based therapy with a tad of a grain of salt. I’m all for evidence based therapy. But if your therapist is more eclectic, bringing in different schools, and some of it’s not evidence base, that absolutely does not mean it’s wrong, it can still be very helpful. It just may be that the things that they do are much harder to study to prove that they’re effective. And therefore you have almost a publication bias favoring the more simple forms of therapy.

Joe Clements 

I have observed something with myself but also with other people. That if you provide an explanation for behavior, even if the explanation isn’t exactly correct, that that itself can be therapeutic in general. So it’s you do X because Y happens and then once somebody labels it and explains it, and a lot of cases the behavior is greatly diminished. Now, I mean, there’s some traumas where that’s not going to be true, right? Sex abuse probably isn’t, that isn’t going to be true of. But a lot of things that just seems to be like if the mind establishes a narrative element has an explanation, that the antagonism that that cognitive issue, produces kind of dulls.

Dr. Grammer 

Yeah, I actually, as part of my psychiatry training at Walter Reed, it was a more classic psychiatry program. So we did a lot of dynamic insight oriented therapy. And that’s, that’s one form of therapy. So you know, we talked about different schools dynamic insight oriented is one of those. And that’s sort of the byproduct of the Freudian era where you’re taking these sort of psychological phenomena that occurring within people’s minds and bring them into consciousness so that people can manipulate them and have more control over it. And a good example is, it doesn’t always have to be like curative, you know, it’s always great in movies and stuff like that. And even some of the literature that’s been published, where the therapist says something that’s like this massive epiphany and the person is suddenly the shackles come off from their symptoms, and like, I’m cured, right. But the reality is, often, it’s a lot of little victories that come along the way. So it’s not uncommon, I’ll meet with a patient. And I can think of an example, more recently, where there was someone who was extremely successful at their job, they were extremely successful as a parent, but they had neglected their own life goals and emotional needs to overcome the symptoms, they had yet still remained sort of logistically successful in the more materialistic sense. So one of the comments I made was, it sounds like you’re constantly sacrificing your own needs to take care of those around you. And that can often lead to you feeling unfulfilled. And they were like, yeah, yeah, I hadn’t really thought about that before. But I think you’re right. And I’m like, well, it’s okay to take care of yourself. And in some ways, taking care of yourself makes you more effective and taking care of others. So while your intention may be to sacrifice yourself, for the needs of others, it may actually be having a more detrimental effect and reaching those goals than you may realize. So let’s do something about this. And it wasn’t so much that I was hoping that they would be cured with this, but the idea that they couldn’t take care of themselves, was a essentially a resistance to them accepting help. So by removing that resistance, it unlocks them to move forward and then say, Okay, I’m willing to do X, Y, and Z treatments. So a lot of therapy, particularly dynamic insert oriented, can be those little victories that over time begin to add up to people making choices where they’re more true to themselves in their field more peace.

Joe Clements 

What would you say the top three therapies being you say? I hear a lot about cognitive behavioral therapy, like, is that one of the top three? Or what do you say are the top three that you’ll find most common?

Dr. Grammer 

Well, there’s most common and there’s, there’s the top three that should be used?

Joe Clements 

Well, let’s go top three, that should be used.

Dr. Grammer 

Okay. Yeah, cognitive behavioral therapy is probably the most talked about. And part of the reason is because of what I was referencing earlier cognitive behaviorial therapy originally sort of described best by Aaron Beck, he wrote this very, very big book. But the latter half of that it was very like circumscribed. This is how you do this, here are the charts that you keep here, the defense’s people use, here’s we’re going to look for distortions in the way that people think about things.

Joe Clements 

And what is cognitive behavior? What defines it in a nutshell, yeah, and

Dr. Grammer 

we’ll get, give me one sec. So So you do these things, and therefore, you know, you have an identified product, therefore, it works. Now, it’s not quite so simple. Beck actually had a lot of nuance to the way that therapy was delivered. And I think that gets diluted out these days, because other people have written books and workbooks on cognitive behavioral therapy. And they’ve left off some of the more complicated parts of themes that can lead to people thinking about things in a certain way. So let me be more specific cognitive behavioral therapy is this idea where you are going to be looking at your thoughts and actions, identifying areas where you may have distorted those in a way that is less fair to yourself. And that those distortions then lead to symptoms. So if you change the automatic thinking, that creases distortions, you can actually begin to change the way that people even perceive the environment around them. And

Joe Clements 

so you’re kind of questioning first principles of people’s thoughts. So in the patient example, you gave the faulty premise is I can’t get help, because then I can’t take care of others. You remove that faulty premise, replace it with something that is healthier, more productive, and then that allows the patient to move forward.

Dr. Grammer 

Yeah, I think in that case, you know, and there’s a lot of terms here. And I don’t want to bogged down too much in these because they can get a little bit complicated. But you know, this idea in cognitive behavioral therapy, where you can have a schema, which is this overriding concept. So in the example I gave someone could have the schema where to be loved, I must sacrifice my own needs. And that’s not true. But in there are a million different sort of distortions, right? And I’ll give a very concrete example, if I was giving a lecture, and someone got up to go to the bathroom, and I’m up there, I don’t know why they’re leaving, all I see is that I see their back heading out the back door, it would be easy for me then to kind of have these thoughts of Oh, man I’m boming it, this person’s leaving, I’m not capturing their attention. And no one wants to be here. And this is terrible. I don’t know why they’re leaving. You know, and there are other people sitting here I’m doing something. Right, right. So so the automatic thought, which is essentially the way that we kind of instantly come to a conclusion, what’s two plus two is four, you don’t have to think about it, you don’t have to navigate. Hopefully, you don’t have to count on your fingers, you just know that. Well, believe it or not, a lot of our day to day perceptions have those same instantaneous conclusions. And we have to retrain our brains into undoing those. So when you look at this distortion, I have of catastrophizing in mind reading this person that’s just walking out the door, right? I go back and say, Well, I don’t know why this person’s leaving, I don’t have the innate capacity to read their mind, the way that they feel also has nothing to do with the way that other people feel in the room. Therefore, to be fair to myself and others around me, I mean, other people are here, I’m doing okay, let’s get done with this talk, right. And when you do that over and over again, and keep diaries and charts and things like that, you begin to notice these themes, and to the schema. And when you get the schemas, then you can sort of begin to almost automatically extrapolate that exercise of reframing those thoughts into more healthy ways. And that’s kind of the core cognitive behavioral therapy. There’s also time limited cognitive behavioral therapy, where you’re like, hey, we’re gonna do this for 12 sessions, teach you these skills and go forward. And then there’s more enduring, like, let’s keep touching up on this over time, so that you don’t lose the exercises, because if you stopped doing it, you may revert back, a great book for listeners to read. And I have no relationship to this person at all, or anything with this book, I think it’s a good book. But there’s an author by the name of David Burns, who wrote the “Feeling Good Handbook,” you can get used copies of the original version off Amazon for like dollars. And what Dr. Burns did was he essentially took the work of Aaron Beck, who wrote the big medicalized version of this, and distilled it down into like, everyday speak, but it is, it is a beautiful representation of cognitive behavioral therapy at its core. And if you want to know if you’re truly doing cognitive behavioral therapy, grab that book, flip through it, read through it, and that will tell you what it’s supposed to be done, like. So what’s number two? Number two, that should be done is interpersonal therapy, okay. And the reason why cognitive behavior therapy and interpersonal therapy I bring those up is the only two therapies that have pretty strong evidence for efficacy in major depressive disorder are cognitive behavioral therapy and interpersonal therapy. Okay, so there are some insurance companies that will not pay for more sort of sophisticated treatments or treatments that are further down the algorithmic line, if you will, until you’ve had courses of cognitive behavioral therapy and interpersonal therapy. But like I mentioned before, be aware of the publication bias that over emphasizes the efficacy of those modalities. That being said, they do show that they work in pretty decent trials. So interpersonal therapy has to do with your sense of identity, how you perceive others, and how others perceive you. Okay, and that does seem to work. And if someone has an incredibly poor sense of self, I mean, we probably your in media, right? So you probably have seen a neurotic singer or something like that, or orator, whatever, public speaker, and they’re like, gosh, I’m doing terrible on this is awful. You’re like you talking about you’re like, awesome at this right? What do you and so how they think the world is seeing them becomes divorced from how the world actually sees them.

Joe Clements 

And that is very common in people who are successful media figures, entertainment, or otherwise, they tend to skew hard, extremely insecure, or hard, relatively narcissistic.

Dr. Grammer 

Right? And and I would argue that a lot of that narcissism is the band aid of insecurity.

Joe Clements 

Oh, yeah, that would make sense.

Dr. Grammer 

Yeah. And you’re right, like, you know, there’s tons of stories of models out there that, by anyone’s definition, are profoundly the medical way to be sort of symmetric in their appearance, but beautiful, you know, in the in the more common vernacular. And yet, they’re like, Oh, I’ve got this slight blemish or slight thing I was wish was different, like, What are you talking about? You’re like the top point zero 1%. So you’re absolutely right. A lot of these people just are cruel to themselves internally. But also, some people don’t communicate well, right. So some people may. And this happens pretty frequently. I’ve someone I work with, for example, and we get into pretty contentious conversation sometimes. And we will be yelling each other agreeing. And I’m like, I agree with you. So so they’re like, I may not be adequately communicating well, that I am in agreement, I may be suddenly reacting to my own emotions in that circumstance. That is something that if it becomes a problem in your relationships, where how you feel doesn’t reflect what you’re communicating, that can then cause problems with surrounding yourself with a supportive network. likewise, if you see other people and perceive them as being critical towards you, and they’re not, if you’re reading between the lines, you’re like, what are you really saying about me? You don’t think I’m a nice guy that can be problematic. So it’s often done in a group setting. And it becomes very concrete. You’ll be like, Mr. X, what did you hear Mrs. Y, say? And then you go, Mrs. Y, is that what you meant to say? And she didn’t know I didn’t mean that at all. As you begin to clarify some of these things in practice skills. Sometimes you roleplay with a therapist, pretend you go to a party, and I’m someone that you don’t know, let’s go through sort of 10 questions you can ask to kind of get through this. That’s a little bit of social skills training, but also just the modeling that helps people develop this comfort with communicating and perceiving communication. So those two forms cognitive behavioral therapy and interpersonal therapy, are the evidence based therapies for major depressive disorder. We’ll talk about it a little bit later in the PTSD episode. But probably the third most common evidence based class of therapies is going to be the exposure based therapies for PTSD where you’re repeatedly exposing a patient to a stimulus that triggers their PTSD phenomenon to extinguish that phenomenon over time. Again, we’ll talk about that, I think, episode five or six or something like that. Now, let’s talk about what’s most common as therapy, okay, because if you call up a therapist an LPC for example, licensed professional counselor, there’s a chance that that person will do supportive psychotherapy. Now, it’s not the way it sounds supportive psychotherapy does not mean Hang in there, Joe, you’re doing great, you know, I’m in your corner. Supportive psychotherapy is let’s look at the things that are healthy defenses. I’m reaching out to the people when I feel lonely, I am trying to eat in a way where I’m making wise choices, I am taking time out for myself. These are things where I’m I’m engaging in healthy, adaptive behaviors and thoughts and your discouraging unhealthy ones. Don’t go out and use crack cocaine don’t engage in high risk sexual activity, right. And so unfortunately, because that’s a more loose kind of therapy, I don’t have a study, I can pull out and say supportive psychotherapy is the cat’s meow, and everyone gets better with this. What I do have are patients who have completed surveys after supportive psychotherapy with a fairly high satisfaction rate. But if you have major depressive disorder, moderate or severe severity, things like supportive psychotherapy have not been shown to decrease core symptoms. So it depends on what your goals are, I think supportive psychotherapy can keep you from making things worse. But if that’s all you’re receiving, and you have moderate to severe level depression, that may not be an effective modality for your treatment, you may have to do cognitive behavioral therapy and or other body based or somatic based therapies.

Joe Clements 

Any others that are commonly used, but probably not effective for major depressive disorder?

Dr. Grammer 

Well, many others, so there are hundreds, if not thousands, of schools of therapy out there. So I’m sure I’m going to miss several. I think people that do things like emotive based therapies where you know, like rage, screaming and hitting each other with pillows, and things like that, that actually, not only hasn’t really shown to be very helpful, and I want to be clear, that’s different than helping people learn to communicate to advocate for themselves or to express emotions. Right, but unconstrained emotion actually can worsen symptoms. So a lot of times in crisis, people want to rage against the sky, if you will, like why, you know, think about Forrest Gump, Lieutenant Dan in the tower screaming at the EPA storm, made for a great scene. And actually, you know, love the actor that played him. But yeah, not very effective.

Joe Clements 

Yeah, my guess is it probably does two things like one is actually decreases your sense of control, because you just did this whole tantrum and nothing changed. And then to also decreases your sense of self control in this situation, because the one thing you could control is your response. And then your response was just to go ham and see what happens.

Dr. Grammer 

Yeah, I think, I think you kind of hit the nail on the head for an important point there. And a lot of therapy, regardless of the School of therapy that’s being used needs to be harm avoidance, don’t do the things that hurt you. So anytime someone’s breaking out the big boxing gloves to go punch your other colleague in group or something like that, like, that’d be the time I’d be like, is this right for me? I think mindfulness, for example, and these other kind of more holistic forms of therapy can be helpful for some people, but they can actually be quite detrimental for some people. So in mindfulness medicine, you’re talking about trying to bring your mind into the here and now, the present, and in some people that can actually be quite effective because they spend way too much time regretting the past and dreading the future. On the other hand, if you have generalized anxiety disorder, and you try to get into that vacuum, of having your mantra, whether it’s home or what have you, or to get into that space, where you clear your mind of the past and the future, what will happen in general anxiety disorder is all your worries will start to leak in, you know, into the room in your mind to say, Well, have you been worried where your kids are okay, and stuff like that. So and I see people struggle with that because like a mindfulness is great for everyone tapping is another form of this where people will tap different parts of the body. It’s another method of sort of mindfulness and grounding to do that. But in some people that may not be helpful. Believe it or not, there are some people with personality types that don’t do well with therapy in general. I mentioned earlier, I think in that first episode schizoid personality, where people get overwhelmed with intense interpersonal relationships. And if they go see this very kind of caring, altruistic therapist, there’s evidence to show that it actually increases their anxiety, and can worsen the underlying conditions like depression, and so forth. So you have to be very careful about the kind of therapy you do for those folks. And so I guess, let’s talk briefly because it’s invoked, you mentioned this in the pre show here. Now therapies become so kind of socialized, I guess, is the right word, 

Joe Clements 

It’s just a commodity now, yeah, press the app button on my phone and a nice person talks to me.

Dr. Grammer 

Yeah. So what is that like? I think we have to be careful, because there is this idea of befriending where someone just acts like your friend, okay? It doesn’t really work for much. I mean, it may help you feel validated and listened to, but as for of course, symptoms, not as much. And so if you do one of these apps, listen, I applaud the apps, because what they’re doing is they’re actually improving access to care, which is a huge problem in this country,

Joe Clements 

And may work for people who don’t have actual major depressive disorder.

Dr. Grammer 

Yes, like life coaching.

Joe Clements 

Yeah.

Dr. Grammer 

So there are some people that don’t have a major psychiatric condition, and they just need a nudge to mirror to reflect into so they can stay on their path, if you will. But with those apps, if you’re doing chatting with someone, you’re missing out on a lot of the subtleties that make therapy effective, including the sort of therapist patient relationship, which can lead to sort of internalizing this image of a common soothing person into your life, the information being provided can often seem superficial and naive. And If it obstructs you from receiving other care, I think that can be problematic. However, if you can do the one on one sessions, and the therapists you’re talking to can give you some sort of cogent response of, here’s why we’re doing what we’re doing, then that becomes a lot more reassuring. If they can’t give you that response, then it might be time to move on. The last thing I’ll say is, therapy is a little bit like a blind date, you can actually meet with a therapist and say, This is not a good match, and have it be no one’s fault. Okay. I would say before you completely discount someone I like to say give them three sessions to interview, if you will. But if after three sessions, you’re like, no way, and there’s some people, you know, after the first

Joe Clements 

Yeah, well, you know, you’re complicated, right? That’s the first thing and so no one’s gonna get you in an hour.

Dr. Grammer 

Yeah, absolutely. And like, I had some people who say, like, is there anyone else I can see, I don’t want to see your Dr. Grammer, because I don’t like your style.

Joe Clements 

Yeah.

Dr. Grammer 

And a good therapist is trained not to take that personally, in some ways, part of the challenge of training to be a therapist is to move outside of social norms of how you interface with folks, because that’s not therapy. That’s just friendship, right? You’re moving into this therapeutic role. And so in the course of therapy, speaking, honestly, for the most part, the therapists feelings don’t matter. Because you’re paying them for help. You’re not paying them. So they feel better about themselves, because they feel like they’re helping.

Joe Clements 

Yeah.

Dr. Grammer 

So in that case, every therapist who goes through training is taught not to take those kind of things personally, and say, Hey, listen, I appreciate you telling me that. And thank you for having the courage to tell me that because that’s not easy to do. Let’s get you linked up with someone, let’s do a warm handoff where if you want I can tell them kind of what we’ve gone through and what seemed to be working or not working and make this a smooth transition. So if you have a therapist that gets defensive or starts getting angry with you, huge red flag might be time to go see someone else.

Joe Clements 

What about people that can’t maintain a relationship with a therapist, because I’ve seen this with people before where they just kind of go through a therapist every three to six months?

Dr. Grammer 

Yeah, there’s something to be said about that. And usually, again, that becomes this idea of resistance where when you start getting into something that’s uncomfortable, people flee, right? And I would encourage people to have an honest inventory of why they’re ending that relationship. Is it really the therapist? Or is it because they’re getting to issues that make you uncomfortable? Because those uncomfortable feelings as much as you want to have them boxed up and sealed in a case and cement? The reality is, they leak out and they come into our conscious mind and they begin to influence our decisions and perceptions and so forth. Now, a good therapist will call attention to that resistance. So if someone’s like Dr. Grammer, I can’t make tomorrow’s appointment and you’re like, this is their time in the row. I noticed it was right after we were talking about such and such event when you were seven. Could those things even be remotely related? Or am I in my reading into this too much? Let’s talk about that. So what makes this difficult to talk about? Why are we missing appointments? So rather than pushing through the resistance like No, no, we’re gonna get back to this, you’re actually supposed to then stop whenever there’s resistance back up a little bit and then talk about the resistance itself to move through it to make it easier for someone. Not all therapists do that. The other thing too is some people perceive therapy to be this kind of review of childhood trauma. And a lot of our formation, I mean, a lot of our record of personality is written by the event prior to the age of 25. And then it becomes a lot more kind of crystallized and less flexible over time. And so that’s one of the reasons why like stuff that happened to you, when you’re five is a much greater impact, potentially, than stuff that happens to you, when you’re 35,

Joe Clements 

Your processing power is a lot lower, too. So all you can do is internalize things when you’re a child, because you don’t understand external factors very well.

Dr. Grammer 

Yeah. And you’re more vulnerable to people that may treat you in a way that’s not healthy as well. Whereas, you know, hopefully, if you’re older, you can be like, I’m outta here.

Joe Clements 

Not sticking around for that.

Dr. Grammer 

Yeah, I think there are people under five, they wish they could do that, right. But if you have a therapist that basically goes back and just like dredges up trauma. That’s not good, either. There’s a way of going back and doing trauma focused therapies. And again, we talked about this in the PTSD episode, I think, be careful, the therapists that watch too much, like listen, I actually kind of like Dr. Phil, he’s kind of entertaining. I don’t know about his therapeutic technique, and voyeurism on TV. But you know, there’s some therapists it’s like, if they’ve watched too much, Dr. Phil, and they’re like, Alright, we’re going to talk about your angry relationship with your mom, again, that’s not necessarily therapy, like, what are you trying to accomplish with that? You want someone to have awareness that those are issues. But you know, at some point, you have to bring that to the here and now and start saying, You were yelling at your boss the other day, man, it sounds familiar. Where else have you said that exact sentence to? And some people are like oh yeah, I used to say that to my mom all the time. Yeah. So what’s the similarity between those things, so you gotta begin to say why it’s important to know those things. So be cautious of therapists that just kind of go through week after week of agony and pain, and just have you descending further and further. The last thing I’ll say, is this on therapy, and I know I’ve kind of jumped around a bit, but it’s man, we could spend eight episodes of nothing but therepy. But you have to be well enough to do therapy. Right. So part of your thing was not only who might benefit from therapy, but who might not benefit from therapy. And we talked a little bit about people with personality styles that get overwhelmed with interpersonal interactions, for example. And there are some conditions that don’t respond to more classic forms of therapy, bipolar mania, for example, that requires a very specific medical treatment. And while you can help keep people out of trouble, you can’t fix mania with therapy alone, no matter how much people want to pretend like you can, but for people in whom it’s not good for, there are some people that lack the capacity for psychological insight, okay, and even the ability to articulate emotion, something that can be impaired. And if every time someone starts looking inward, they get enraged and stuff like that. They may not just be, you may not be a great candidate for therapy, or someone who has unstable housing, or unstable employment, like, they’re more concerned about being able to

Joe Clements 

Even get there. Yeah.

Dr. Grammer 

Exactly. They may not have financial resources. I mean, you never want to make someone choose between food and their therapy. And then there’s people with very severe symptomatology. And this is important because people with major depressive disorder severe, okay, where their ability to shower is impaired, or their ability to even eat becomes impaired, and they’re not sleeping, for example, therapy, if you do it right actually is a bit of an exercise. Think of it like physical therapy for the brain, I actually think that’s a pretty decent way of conceptualizing it. And it does change the way that your brain functions. therapy has been shown to change sort of genetic expression, and neural networks and so forth. There’s a physiologic response. That’s not so hard to believe. If you exercise your leg, your thigh muscle, for example, will get stronger. So if you exercise certain areas in your brain, those areas can get stronger, for example, but the worse your symptoms, the harder it is to benefit from therapy, because you’re just trying to tread water.

Joe Clements 

Yeah you might need surgery.

Dr. Grammer 

Yeah, exactly

Joe Clements 

Or the equivalent of in your analysis. Physical therapy is to talk therapy as maybe surgery is to other treatments.

Dr. Grammer 

Exactly. So if you find therapy is just too painful and too uncomfortable, I think listeners really need to then talk to either their primary care provider or go see a psychiatric nurse practitioner or psychiatrist or a behavioral health physician assistant, and see whether or not medications may sort of improve your resiliency enough that you could get full advantage of therapy. One of the cruel ironies of therapy is it tends to benefit those who most need it the least. Now, that does not mean therapy doesn’t work for people at all with more moderate severe symptoms, but the efficacy of that can wane a bit, because you just don’t have the bandwidth to make the progress you need to so if that’s holding you back, add on additional treatments so that you can benefit from it. Once you’re better. Once you’re feeling a little bit better. Then don’t slack up on the therapy, that’s the time to really hit to sort of entrenched and sustain those changes, and begin to correct or mitigate some of the predisposing psychological factors that may have helped precipitate the depressive episode in the first place.

Joe Clements 

Last question on some of this can somebody who’s incapable of psychological introspection, actually be mentally healthy? If you are incapable of understanding and evaluating your own motivations? Even if you’re medicated? Even if you get medication, you do other therapies? Could you actually be mentally healthy if you aren’t capable of doing that?

Dr. Grammer 

Yeah, there is no idealized self, right? I mean, it’s individualized, but there’s no one size fits all. And for some people, psychological ignorance may be bliss. And they may be completely content with the things they do in life. And they don’t need to think too much about their underlying motivations or the way they perceive things, when they go do something that they enjoy, they enjoy it, when they’re exposed to something they don’t enjoy, they don’t enjoy it. And that’s just the way the world is. And it’s a mistake for a therapist then to potentially go in there and start unroofing a bunch of stuff that is adequately defended, compartmentalized and being contended with in the way that that patient needs. So it’s interesting, because while we have these different schools of therapy, and we have these studies that show what works and what doesn’t, in the end, the best therapists tend to be those that have the wisdom to know what schools to pull from, for that specific patient. And it does require the therapist have flexibility in their model. So if you see a therapist where everything is, and we forgot to mention DBT therapy, okay? What does that mean? Dialectical Behavioral Therapy is a Dr. Linehan essentially kind of created that school of thought where you’re going through a lot more kind of adaptive ways of dealing with events that have previously been maladaptive both in the way that we think about them and act on them. So it is meant to stabilize and improve decision making. Alright, so if you get a certain amount of emotional distress, and your previous method of contending that with that was to burn yourself so that you could ground yourself and feel something other than the emotional pain? Well, let’s start talking about maybe different ways of contending with those emotions. So you don’t have to do that. Alright, as an example. And it’s it’s kind of a subsection and sorry for the DBT therapists out there in my mind is kind of a subsection of C, CBT, but a little bit more nuanced into that kind of particularly adaptive mechanisms, if you will. So

Joe Clements 

What percentage of people experience relief or progress from symptoms with talk therapy of any sort?

Dr. Grammer 

That’s a good question. Just to finish up on my prior thought I’d because I forgot to close it out. I think if you see a therapist where everything is DBT, it’s like seeing a carpenter where everything is a nail, and all they have is a hammer, like, you really want someone that has a whole toolkit with them, if that’s what you need. Now, on the other hand, if you have like 10 nails that need to be nailed in, yeah, get a person with a hammer, right. So again, just make sure you tailor it to yourself. Alright. And so I’m sorry, your question was,

Joe Clements 

What percentage of people approximately experience relief from talk therapy? And or what percentage don’t?

Dr. Grammer 

Yeah, it depends on the study you look at. But let’s take cognitive behavioral therapy, because that’s probably the easiest to do. So anywhere from half to two thirds of people receiving cognitive behavioral therapy can have improvements in symptoms. There were studies and this is good to know, there were studies that were done, where they gave people either medicines, cognitive behavioral therapy, or psychoeducation, which is, here’s what depression is so forth. And that’s the sham if you will, the placebo via psychoeducation. And what they found was, meds and therapy are better than psychoeducation alone, and were equal to each other. In addition, there were studies that have looked at meds therapy or meds plus therapy, and meds plus therapy was better than meds and therapy alone. Finally, after a depressive episode, let’s say you come in and see me and I put you on Lexapro, which is Escitalopram, 20 milligrams, and you’re like, hey, this has me all fixed? Well, you’re still at risk of having a return of your symptoms. But if you do cognitive behavioral therapy, or take medications, the risk of relapse goes down, and it goes down equivalently between those two mechanisms, so particularly in mild to moderate depression, I think there’s a completely valid argument to do either meds or therapy, or both. If you’re playing the odds, you’re better with both. And I think once you’re feeling better, if you keep taking meds or keep doing therapy, the chance that depression will come back is less.

Joe Clements 

And for, and this is probably a good place to close out for those for whom medication and talk therapy doesn’t work, there’s a whole gamut of other options that are most of them are relatively recent in their development, correct?

Dr. Grammer 

Yeah. And so for the listeners, like we started off very intentionally with kind of classic behavioral health stuff. We talked about depression. And now we’ve talked about therapy. In the next episode, we’ll talk about medications. But it’s important that you know that 1/3 of people with major depressive disorder will not get better with medicine therapy, no matter how long no matter what school, no matter how many trials, it just doesn’t get better. And rather than thinking about, and this is really important, rather than seeing that as you failing the therapy, I want people to understand that’s the therapy failing you. Think about the antibiotic model. If you have an ear infection, and I put you on an antibiotic, but that bacteria causing the infection is resistant to it, you can take it the way you’re supposed to, you can absorb it the way you’re supposed to, and it can not work. Well, depression therapy is the same thing, we just aren’t as good yet kind of figuring out what forms of depression with the underlying abnormalities in brain are more resistant to medications and psychotherapy than other forms of depression. There are people working on that and there are people out there in the community who pretend to be able to tell you that but I’m telling you right now that that is still in the world of science fiction, I do think in the next five to 10 years, it’ll be more clinically applicable, we’re just not there yet in end of 2021, here, if you’re in that third, for whom medications therapy have not given you relief, don’t assume blame for that. See that as it is time to move down the algorithm of evidence based care to get that better. And that can involve things like transcranial magnetic stimulation therapy, which we’re going to talk about ketamine or Escitalopram therapy, which we’re going to talk about, or even things that are experimental now, like psilocybin, which is on the street referred to as magic mushrooms, which we’re going to talk about. So don’t accept that a lack of improvement means that from those two modalities, medicine therapy means that you can’t be helped quite the opposite. Now, in the last 10 years, there’s been a revolution in mental health care where we have a lot more tools in our tool chest than we used to.

Joe Clements 

So wrapping up multiple different types of therapies that we’ve talked about. Different therapies may work for different people with different issues. It is a little bit of you got to find the right therapist doing the right therapy or preferably the therapist with the wisdom to know which therapy to use in your certain case, even with medication, which makes it more effective for major depressive disorder doesn’t always work. And next episode, we are going to talk about medication anti depressants, anything you want to say about the next episode before we close.

Dr. Grammer 

Yeah, medications on that next episode, kind of like we talked about different schools of therapy. There are different kinds of antidepressants. There are different augmentation strategies of antidepressants. And actually now in the last 20 years, we have seen a lot more evidence based algorithms that allow us to make kind of very formulaic decisions on which ones to use, what to do when they don’t work, what to change to how to augment with. So if you feel like your provider that’s giving you antidepressants is like choosing the dartboard and dark method. You definitely want to tune in because we’re going to give you a lot of information on how someone should be choosing a medication. I’m gonna go back and correct one thing I said earlier about DBT therapy. I misspoke and I thought it did at the time so dialectic behavioral therapy not dialectical. I don’t think that’s word but dialectic behavioral therapy is what DBT is. So to the DBT therapists out there. I’m sorry. But yeah, tune in next episode, we’re going to really get into the weeds of meds because that’s what most people get when they get depressed and I want people to know what right looks like when a medication is chosen.

Joe Clements 

Alright, sounds good.

Dr. Grammer 

Joe, I will see you next time. Thank you again for joining this time and yeah.

Joe Clements 

Yep, looking forward to it

Dr. Grammer 

Meds next episode. Stay tuned in. Thanks, guys. Bye

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