Key moments, in order
Treatment has three pillars: medical (medications, avoiding substances), the mind (usually psychotherapy), and life changes. Medications will not solve problems; they help you solve them.
Psychiatrists should coach and follow up on psychotherapy and lifestyle recommendations too, not only prescribe. Lifestyle treatments cost effort and time, not money, and are too often skipped in favor of jumping to medications.
Exercise helps mood, anxiety and sleep. It is a crucial pillar of health.
Keep it small and sustainable. A two-minute walk outside five days a week is better than a plan for the perfect workout that never gets done.
The most important part is the practice of setting goals and then achieving them. It sounds silly, but that alone can be encouraging.
Depressed patients wait to get motivated and the motivation never comes. Behavioral activation flips the script: you do things in order to start feeling better, not the other way around.
Plan goals expecting that you may not follow through, and that is OK. Simply putting the goal down is the first step.
To find goals, ask what they used to enjoy before they felt this way, and if there is no good answer, what they would like to be doing.
Do not set patients up to expect to enjoy it. Hope they do, but have them act without that expectation, and base the plan on what they are willing to do.
An exercise partner can be the thing that keeps a routine going.
If existing or past relationships were not safe enough or not giving the person what they need, the work eventually is to find new relationships or build new ones. Shared activities are one way to do it.
Social supports, people you can rely on and talk to about your feelings, thoughts and wishes, are a very important part of long-term recovery. The need for attachment and relationships is a human need, not an add-on.
Ask the patient to identify for themselves something objectively safe that they trust: people who are at least basically not aggressive and basically OK to spend time with.
Work and school seem to have an automatic protective effect because of their baked-in socialization.
If someone's past relationships are all with people who habitually use, going back to them carries a huge risk.
Aim for regular experience with other people that is as close as possible to in person. Chatting and commenting on social media does not count.
At high doses it puts you into an intoxicated, delirium-like state where you cannot consolidate memories or put your thoughts together the way you normally do.
They belong in the same category as alcohol, benzodiazepines and cannabis: things that make people feel as if they are getting better or sleeping when they are not necessarily getting better or sleeping.
Stabilize sleep and patients get a lot of their mental health back on their own, because so much else cannot happen if they are not sleeping.
It is accessible, low harm and low cost, and it weaves into sleep regulation, behavioral activation and exercise at once.
Three necessary and sufficient parts: deliberate attention (on purpose), to the present moment (the ongoing now, not the past, the future or what should be), without judgment. And it is a practice, something you actively do.
Do not expect it to make you feel good, because that adds pressure, and expect to fail.
It means stepping back and seeing thoughts as a process happening within you rather than as you. Getting closer to the observer, not the thoughts, urges and emotions that pop up, opens a little space before you respond. The CBT term is cognitive defusion.
The DBT mindfulness module is the most concise and varied set of exercises for short visits. Hand out the DBT mindfulness handouts to anyone, not just patients with personality problems. Early in training, searching DBT mindfulness PDF works fine.
Give patients the handouts, not the skills training manual, which is too detailed for non-clinicians. The mindfulness handouts are good for most patients, not only those with a personality condition or cluster B traits.
We do not recommend a workbook until we have a good diagnostic idea of what is going on and a working idea of the patient's core problem.
ADHD and executive dysfunction of any kind: Mastering Your Adult ADHD or the Executive Functioning Workbook for Adults. Frankly, though, the best thing is working with someone.
ACT: The Happiness Trap is our go-to and really good. ACT integrates a lot more mindfulness.
Some ACT workbooks have a teen version with pretty much the same content. Even adults may find it more fun to read.
We evolved in rhythms (night and day, the seasons, the tides), and the body loves rhythm and regularity.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.