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Using Equine Therapy as Mental Health Treatment

What Horses Bring to the Therapeutic Process

Animals can offer an extraordinary amount of emotional support. Beyond the pet-owner relationship that many of us have lovingly experienced, animals are sometimes used in therapeutic settings to help clients proceed through challenging emotional experiences.

Equine-assisted psychotherapy allows for horses to be incorporated into the therapeutic process. With matured horses weighing anywhere in the range of 900 to 2,000 pounds or more, it might feel a bit intimidating to have such a large, majestic creature sitting in your therapy sessions. However, equine-assisted therapy is growing in popularity due to its experiential approach and some burgeoning evidence of its effectiveness.

There are a variety of terms used to describe or reference equine-assisted psychotherapy, such as:

Equine-assisted mental healthEquine-assisted counseling

Equine facilitated psychotherapy

Equine-assisted therapy

The last term, equine-assisted therapy, can also often refer to other forms of therapy where horses are used, such as with occupational therapy.

Who It's For 

Equine-assisted psychotherapy (EAP) can be used with a variety of populations and in a variety of therapeutic settings. In fact, horses can be used in counseling with individuals of all ages, even with families and groups. Equine-assisted psychotherapy is often not the sole form of treatment, but rather a complementary therapeutic service to be used in partnership with more traditional treatment. Offering a much different experience than traditional talk therapy, EAP brings people outdoors and offers an opportunity to use all senses while learning and processing through emotional challenges.

Children and Teens 

Equine facilitated psychotherapy may be just as effective with children and teens as it is with adult clients. As with adults, children can experience challenges such as trauma, anxiety, depression, PTSD, and more. Equine therapy offers them a therapeutic environment that can feel less threatening and more inviting than a traditional talk therapy office. The majority of children participating in EAP are between the ages of 6 to 18 years old. They often find it difficult to open up and process painful emotions and experiences. Equine-assisted psychotherapy allows youth, and people of all ages, to work on issues such as:

Emotional awareness

Assertiveness

Social skills

Confidence

Trust in self

Trust in others

Empathy

Impulse control

Problem-solving skills

Developing and maintaining relationships

Benefits 

Although a variety of animals can be used in the psychotherapeutic process, horses offer unique traits that have come to make them a top choice for animal-assisted therapies. According to anxiety expert Dr. Robin Zasio, horses bring the following unique elements to the therapy process.

Non-Judgmental and Unbiased 

As much as humans, especially therapists, do our best to offer a safe space for clients to explore deep emotional hurts and painful experiences, it can be uncomfortable for clients to openly share their thoughts.Building therapeutic rapport can take time, working toward building trust and practicing vulnerability in session. Having the horse present may offer a sense of peace, as they only will react to the client's behavior and emotions with no threat of bias or any judgment of their emotional experience.

Feedback and Mirroring 

Horses are keen observers, vigilant and sensitive to movement and emotion. They often mirror a client's behavior or emotions, conveying understanding and connection that allows the client to feel safe.This also allows for clients to maintain a sense of self-awareness, using the horse's behavior and interactions for feedback and opportunities to check in and process what is happening in the moment.

Managing Vulnerability 

As clients might find themselves vulnerable when trying to open up about emotional challenges, past experiences, or life transitions, the horse can offer a reference point to use for processing.If something feels too painful to speak of, it can feel a bit easier for clients to process using the horse as an example, or to align their experience with the horse's experiences in the moment. Externalizing the content in this way can make things easier to approach and process through.

Conditions 

Equine therapy has some evidence supporting its effectiveness in helping to manage several conditions.

Anxiety 

Anxiety affects more than 17 million Americans. Although a level of anxiety can be felt by many of us at points in our lives, especially around experiences involving change and uncertainty, there are times when people experience anxiety that meets clinical diagnostic criteria. Anxiety-related conditions include:

Separation anxiety

Selective mutism

Specific phobia

Social phobia

Panic disorder

Agoraphobia

Generalized anxiety disorder

 Many people who struggle with anxiety find themselves stuck in worry about their past and fearful about their future. As Dr. Zasio points out, working with a horse during the therapeutic process can create an opportunity for clients to "... stay present and focused on the task at hand."

Since horses are vigilant and sensitive to behavior and emotions, they can sense danger and respond with a heightened awareness, which typically leads to a change in their behavior and possible attempts to get away. Clients who struggle with anxiety can relate to this developed ability to sense danger cues and respond in a heightened way.

Processing challenges through the behavior of the horse can be easier for clients than speaking directly about their own personal experiences with anxiety.

Another benefit to using equine-assisted psychotherapy in the treatment of anxiety is to help clients practice vulnerability in a safe environment. As clients learn to interact with the horse and try new things, they are being asked to step out of their comfort zone with the help and support of the therapist and the horse. Clients can then process their experience, such as the fears and challenges, as well as any insights, discoveries or victories in those moments during therapy.

PTSD 

Post-traumatic stress disorder (PTSD) can feel debilitating, marked by increased arousal and reactivity, intrusive memories and nightmares, and avoidance symptoms after a traumatic event. According to the Anxiety and Depression Association of America (AADA), it is estimated that 7.7 million people aged 18 or older struggle with PTSD. Children, teens, and adults can struggle with PTSD.

Although people can experience a variety of traumatic events that could influence the development of PTSD, those who have experienced sexual assault, as well as veterans who have experienced combat, are populations who tend to have higher rates of the development of PTSD.

The use of equine-assisted psychotherapy in the treatment of PTSD for veterans is growing. Tess Hassett, a riding instructor at the Northern Virginia Therapeutic Riding Program, has a background in clinical psychology and is working with veterans using EAP.

Describing her work with veterans, Hassett noted, "A lot of them have said that after what they've been through with their PTSD and depression, they never thought they'd be able to bond with someone again and feel that personal connection. But with their horse, they're feeling that connection. They're able to take that into the rest of their lives and into their relationships."

Addiction Treatment 

It is known that drug and alcohol addiction continues to rise and be problematic in the United States. The Center for Disease Control estimated that over 72,000 people died from a drug overdose in 2017. Many of those were due to the opioid epidemic, with approximately 50,000 deaths occurring as a result of opioid use. The need for effective therapies to help treat addiction is at an all-time high.

Equine-assisted psychotherapy offers a unique approach to working with addiction and those with co-occurring conditions. A co-occurring condition, what used to be referred to as a dual diagnosis, describes someone who struggles with addiction in addition to having another mental health condition. This is quite common for those with substance abuse and addiction challenges, as the additional concerns can include a variety of things, such as anxiety, depression, OCD, or PTSD.

The ultimate goal of addiction treatment is to help clients live sober, healthy and productive lives. Many times in addiction treatment, clients are also working hard to heal hurts within relationship dynamics, such as within a family or with their partner. Learning to trust, practice vulnerability and communicate effectively can be a challenge during this treatment process.

EAP can help clients learn how to develop a sense of trust through their interactions with the horse, gaining a sense of safety, building relationship, encouraging clients to be vulnerable as they learn new things and experience interactions with their horse.

ADHD 

Attention deficit hyperactivity disorder (ADHD), is an additional area where equine-assisted psychotherapy can be helpful. Some report EAP is appealing to adults and youth with ADHD because it offers them an active, fun, hands-on experience.

During equine-assisted therapy, the client is typically with a trained therapist, an equine specialist, and the horse. There is no riding necessarily involved with equine-assisted psychotherapy. Rather, the focus is on presence, attention, mindfulness, boundaries, social cues, and more.

Kay Trotter, PhD, a licensed professional counselor, author, and founder of Equine Partners in Counseling (EPIC) Enterprises, was one of the first to dedicate research to the effectiveness of equine-assisted psychotherapy.

Trotter found that introducing horses to the therapeutic process showed significantly increased positive behaviors while reducing negative behaviors.

Her study was one of the first published on the effectiveness of EAP, published in the Journal for Creativity in Mental Health.

It has been shown that clients can experience a variety of benefit from equine-assisted psychotherapy, such as:

  • Reduced aggression

  • Improved focus

  • Improved adjustment to routines and guidelines

  • Increase in self-esteem

  • Increase in self-respect

  • Friendships feeling less stressful

For clients struggling with ADHD, the sense of accomplishment in an equine-assisted psychotherapy session can be of great benefit. As a licensed clinical social worker, Kit Muellner describes that "... clients feel that they've achieved something on their own, rather than being told to do something by a parent or teacher. A 1,500-pound animal responds the way you want him to because you were able to focus. So you've accomplished something you wanted to do, versus something that somebody else wanted you to do."

This sense of accomplishment can feel significant for anyone, especially someone who struggles with ADHD. In those moments, they are getting instant feedback from their horse and learning how to develop trust, communicate effectively, and how to work toward meeting a personal goal or milestone.

How The Loss Of U.S. Psychiatric Hospitals Led To A Mental Health Crisis

A severe shortage of inpatient care for people with mental illness is amounting to a public health crisis, as the number of individuals struggling with a range of psychiatric problems continues to rise.

The revelation that the gunman in the Sutherland Springs, Texas, church shooting escaped from a psychiatric hospital in 2012 is renewing concerns about the state of mental health care in this country. A study published in the journal Psychiatric Services estimates 3.4 percent of Americans — more than 8 million people — suffer from serious psychological problems.

The disappearance of long-term-care facilities and psychiatric beds has escalated over the past decade, sparked by a trend toward deinstitutionalization of psychiatric patients in the 1950s and '60s, says Dominic Sisti, director of the Scattergood Program for Applied Ethics of Behavioral Health Care at the University of Pennsylvania.

"State hospitals began to realize that individuals who were there probably could do well in the community," he tells Here & Now's Jeremy Hobson. "It was well-intended, but what I believe happened over the past 50 years is that there's been such an evaporation of psychiatric therapeutic spaces that now we lack a sufficient number of psychiatric beds."

A concerted effort to grow community-based care options that were less restrictive grew out of the civil rights movement and a series of scandals due to the lack of oversight in psychiatric care, Sisti says. While those efforts have been successful for many, a significant group of people who require structured inpatient care can't get it, often because of funding issues.

A 2012 report by the Treatment Advocacy Center, a nonprofit organization that works to remove treatment barriers for people with mental illness, found the number of psychiatric beds decreased by 14 percent from 2005 to 2010. That year, there were 50,509 state psychiatric beds, meaning there were only 14 beds available per 100,000 people.

"Many times individuals who really do require intensive psychiatric care find themselves homeless or more and more in prison," Sisti says. "Much of our mental health care now for individuals with serious mental illness has been shifted to correctional facilities."

The percentage of people with serious mental illness in prisons rose from .7 percent in 1880 to 21 percent in 2005, according to the Center for Prisoner Health and Human Rights.

Many of the private mental health hospitals still in operation do not accept insurance and can cost upwards of $30,000 per month, Sisti says. For many low-income patients, Medicaid is the only path to mental health care, but a provision in the law prevents the federal government from paying for long-term care in an institution.

As a result, many people who experience a serious mental health crisis end up in the emergency room. According to data from the National Hospital Ambulatory Medical Care Survey, between 2001 and 2011, 6 percent of all emergency department patients had a psychiatric condition. Nearly 11 percent of those patients require transfer to another facility, but there are often no beds available.

"We are the wrong site for these patients," Dr. Thomas Chun, an associate professor of emergency medicine and pediatrics at Brown University, told NPR last year. "Our crazy, chaotic environment is not a good place for them."

Most hospitals are unable to take care of people for more than 72 hours, Sisti explains, so patients are sent back out into the world without adequate access to treatment.

In order to bridge the gap between hospital stays and expensive community-based care options, Sisti argues for "a continuum of care that ranges from outpatient care and transitional-type housing situations to inpatient care."

While President Trump and others have claimed a connection exists between mental illness and the rise in gun violence, most mental health professionals vehemently disagree.

"There is no real connection between an individual with a mental health diagnosis and mass shootings. That connection according to all experts doesn't exist," says Bethany Lilly of the Bazelon Center for Mental Health Law.

Sisti says the stigma around mental health is "systematized" in our health care system, more so than in the public view.

Health care providers are "rather leery about these individuals because these people are, often at least according to the stereotype, high-cost patients who maybe are difficult to treat or noncompliant," he says. "I think the stigma that we should be really focused on and worried about actually emerges out of our health care system more than from the public."

Source: https://www.npr.org/2017/11/30/567477160/how-the-loss-of-u-s-psychiatric-hospitals-led-to-a-mental-health-crisis?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=202901

How Strengthening Relationships with Boys Can Help Them Learn

Years ago, when Michael Reichert’s oldest son was born, he and his wife made a commitment to shield him from the “toxic pressures and cultural norms that we believed would try to steal our son’s humanity from him.” 

But it turns out that parents can’t build a wall around their children, says Reichert, a clinical psychologist and author of "How to Raise a Boy: The Power of Connection to Build Good Men." What parents and teachers can do is strengthen boys’ resilience to be themselves.

Reichert is hopeful that a new space is opening up in how we think about boys and boyhood. For generations, he says, “we have rationalized a wide range of losses and casualties” by repeating intractable myths: “Oh, that’s just the nature of boys, or boys just don’t do as well in classrooms, or boys don’t do well with emotional intimacy.” 

These persistent stereotypes have influenced how we interacted with boys from infancy, says Reichert, and infiltrated our classrooms and playing fields. For example, he points to a long-term study of boys between ages 4 and 6. Researchers found that boys dramatically changed how they related to others during these years as they “absorbed norms for how they were supposed to act as boys.” They traveled from “presence to pretense,” says Reichert—from being emotionally honest in relationships with peers to using posturing and bravado as they adhered to group norms about how boys “should” behave. In molding their behavior to this standard, “it cost them their authenticity, exuberance, and confidence.”  

Boys Are Relational Learners

There are troubling statistics about boys in K-12 schools. They are more likely to drop out of school than their female peers, and according to data from the Department of Education, boys account for approximately 70% of all suspensions and expulsions, a rate that is disproportionately higher for boys of color. 

To support boys in our classrooms, Reichert points to one robust, consistent finding from his 30 years of research: boys are relational learners. They learn best in the context of strong, supportive relationships. 

In one study, Reichert and his team gathered data from 2,500 teachers and students in six different countries.  He asked the boys and their teachers one simple question: “What’s worked?” For teachers, what has worked to help you reach boys? For boys, what have teachers done that has worked to support your learning and engagement? When the researchers coded the data, a couple of themes emerged. 

First, effective teachers used strategies to capture boys’ attention and then carried that energy into the lesson. The strongest teachers entered into a relationship with the class, using feedback from students to refine the lesson until it worked.

But another dominant theme came from the boys themselves. “In the survey, we said, ‘Please don’t mention names or provide identifying information,' ” says Reichert, but the boys ignored those instructions and described teachers’ personalities in detail. They cared about the relationships they had with teachers. 

“We, the adults who design the structures and pedagogy they experience —we were missing something. The boys, however, were very, very clear about it: They are relational learners. This is first base.” 

Healing Relationship Breakdowns

If relationships are central to engaging boys in academics, then teachers need tools for healing inevitable “relational breakdowns.” 

“Every teacher in every classroom has some students who they have a hard time working with,” says Reichert. And in any relationship, there is a natural cycle of connection, disconnection, and then reconnection.  But this process does not always go smoothly. After teachers have tried multiple strategies for reaching a student, they can enter “defensive, self-protective mode,” says Reichert, thinking, “I’ve done everything I can, so the next step is his” or “That boy’s learning issues or behavior or family issues are just too much.”  

Reichert’s research found that, for boys, these relational breakdowns with teachers were highly consequential, causing them to construct self-concepts around failure and to turn off from certain subjects or school altogether.

“Here’s the rub,” says Reichert.  “In our research, we have heard about every kind of problem, and we have also heard from boys who were being reached and transformed” despite those problems. “Every boy, theoretically, can be reached by a teacher or a coach,” he says, and adults need to hold out hope that “if they find the right relational approach, they will be able to reach the boy they are having a hard time with.” 

Reichert contends that the job of being a relationship manager “follows the professional,” and that as professionals, teachers need to take the lead in “instigating repair for relationships that have been damaged.”

Why? In his research, he found that even high-achieving boys struggle with approaching teachers when a relationship has soured. “I put together a focus group of boys at one school– top students. When I asked, ‘Do you have breakdowns in relationships with teachers?’ they were immediately able to tell stories.  What did you do to fix it? Nothing, they said.”

When he probed them to explain why, the boys described a power asymmetry with adults. They did not perceive that it was within their role to initiate restorative conversations. 

Of course, this also speaks to the need to coach boys with concrete strategies they can use when they are in a conflict with a teacher, says Reichert, and parents can help with this. “We need parents to sign up to the idea that the relationship between the teacher and the student is primary. Our job is not to swoop in and solve the problem but to empower the boy to go back to the teacher and work it out.” 

Creating a System of Support

If schools want to reach boys, strengthen their emotional resilience, and help them stay engaged in school, school leaders need to focus on “relational learning” from the top down. Take a look at mission statements, professional development, schedules, and class sizes. Do these basic structures support transformative relationships between teachers and students?

Teachers and coaches also benefit from peer networks that can help them “reset their own thinking about a relationship that has gone south.” Reichert suggests structuring small groups where teachers can safely present a case about a boy they have been struggling with -- describing what’s happening, what’s been done, and how they feel. “It breaks teachers’ hearts when they can’t make it work with a student,” says Reichert. These peer networks normalize the struggle and provide an opportunity to receive emotional support and practical, strategic feedback.

Parenting Emotionally Resilient Boys

The most basic way to support boys’ emotional and character development is also the simplest: listen to them. “Listening is the most important tool parents have for building boys’ resilience,” says Reichert. “I haven’t found a boy who doesn’t have a story he wants to tell. Boys are simply not getting the opportunity to be listened to deeply.”

Both boys and girls have rich emotional lives, but the expression of these feelings may differ because of cultural expectations. “We tell girls not to show anger, to be nice,” says Reichert. “And we tell boys not to show vulnerability or fear, to suck it up or man up.” 

When parents open up space for boys to talk, they can nurture a healthier range of emotional expression. “Establish with your son that you are interested in him,” says Reichert. “Yesterday, for what duration did you listen to your son? Not correcting him, listening. Often we are simply not very good at it because no one listened to us much.” 

Reichert advocates scheduling a block of time each week—even 30 minutes—where the only task is to “accompany your son on anything he wants to do with you.” That might be playing video games or listening to music. Consistency is the key, because “a boy can come to count on there being a space where he can have a parent's full attention.”

When boys are cut off from their ability to process intense emotions, they are going to act it out in some way—whether that’s teasing siblings or resisting homework. This is almost always a cry for an intervention, says Reichert. He recommends calmly employing the listen-limit-listen strategy.  First, listen to your child’s complaints or frustrations—the emotions that are on the surface. Then, limit the harmful behavior (“I’m not going to let you treat your sister this way. I’m not going to let you lie to me about your homework. You are better than that.”). When parents set limits, “more emotions will flare into the open,” says Reichert, and right beneath the surface will be another layer—such as a teacher who is giving him a hard time or a peer conflict—that “you would never have found out if you didn’t give him space to peel back the layers and help him be himself.”

Ultimately, what boys really need to thrive is a strong connection to at least one stable, loving adult, says Reichert. “Here’s what we are trying to accomplish: every boy known and loved, every boy having the sense that someone has ‘got him’—that someone who knows who he his and what he’s facing and really cares.”  They need a relational anchor, and parents, teachers and coaches can all be “that someone” in the life of a boy.

California Considers Permitting Students Excused Mental Health Days

Parents, educators and clinicians are seeing an alarming increase in mental health problems among young people. Various national surveys show the rates of depression, anxiety, and suicide on the rise, but what to do about it is less clear.

In July of 2019, Oregon passed a bill that allows students to take excused absences for mental health related issues. Students advocated for the bill, saying it would reduce stigma about mental health issues, and encourage young people to seek the treatment they need.

Now, the California legislature is considering something similar. State Senator Anthony Portantino has introduced a bill that would change the education code to allow for mental health related excused absences. For him, mental health is a personal issue.

"I had a brother who took his own life," Portantino said. "And one of the reasons I talk about it is so people understand that mental health issues affect all of us."

He says anything that reduces stigma could go a long way to prevent tragedies like the one his family suffered.

"It's not the time to be shy. It's the time to bring these conversations out of the shadows so we can help those who need it."

Portantino isn't concerned that students will abuse the excused absences. If anything, he thinks it will take a lot of convincing to help families drop the barriers they hold around mental health.

But what would this really mean to schools?

"Young people are already missing school because of mental health challenges," said Jenn Rader, director of the James Morehouse Project at El Cerrito High School just outside of San Francisco. "So if this would make that reality more visible for all of us, and bring into sharper focus for all of us what it is we’re all up against, that would be a positive step."

Rader hadn't heard of the legislation, but was intrigued. She'd like to see what results Oregon sees a year into implementation, but agrees with Portantino that reducing stigma around mental health would be valuable.

El Cerrito High operates on a block schedule, which means each student only has four classes a semester with a year's worth of material condensed into each class. That makes it extra difficult to catch up when students miss a lot of instructional time. Rader says there's a clear correlation between students with mental health challenges and absences, especially for those with anxiety.

Dr. Mark Reinecke of the Child Mind Institute says the state needs to tread carefully with legislation like this. He understands the need for parity between mental health and physical health, but says it all depends on the specific situation.

“There are some situations where this entirely sensible and others where it doesn't make sense," Reinecke said.

Take anxiety, for example. Allowing kids with school avoidance problems or social anxiety to stay home from "is absolutely the wrong thing to be offering them. For those youngsters, what we want is exposure, we want the youngster to approach the things they fear."

Reinecke says letting anxious students avoid school only reinforces the behavior. But kids aren't doomed to suffer with anxiety forever. Research has show Cognitive Behavioral Therapy to be an effective treatment. For a student with debilitating depression, on the other hand, an excused absence to see a therapist may be very helpful.

The problem, says Reinecke, is that parents make these decisions in different ways. Some parents take a lot of convincing to call the school if a child is sick. Others, let them stay home at the slightest sign of fever. Excused absences for mental health issues would be similarly murky, he said.

If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (En Español: 1-888-628-9454; Deaf and Hard of Hearing: 1-800-799-4889) or the Crisis Text Line by texting HOME to 741741.

How To Start Therapy

Feeling anxious? Overwhelmed? Unhappy? Not sure what you're feeling at all? These might be signs that your "check engine" light is on and seeing a therapist could help. 

If the mere thought of trying to find help seems overwhelming, you're not alone. Plenty of people put off seeking treatment or try to ignore symptoms because mental health is often easier to brush off as not urgent. 

"We feel like there's a hierarchy of pain, and if our problem doesn't feel big enough, we wait until we're basically having the equivalent of an emotional heart attack before somebody will make that call," says Lori Gottlieb, a psychotherapist, advice columnist and author of the book Maybe You Should Talk to Someone.

On top of that, the process of researching and scheduling that first appointment can be an emotional burden on its own — but procrastinating often allows the problem to grow. If you wait until things get really bad, the harder it will be to address.

We've got four tips to help you make therapy work for you. Be sure to listen to the Life Kit episode "How To Start Therapy" for more advice from experts who know that this is more than just making a phone call. If it were that easy, you'd have done it already!

1. Acknowledge stigmas that might be holding you back from seeking help.

The fear of being stigmatized can keep us from seeking treatment. Our attitudes about mental health likely come from family, friends, society at large, the media — and even our own inner voices.

"I think that a lot of people feel like if they start therapy, that means something's wrong with them and other people might look at them differently," says Gottlieb.

The reality is that people close to us often notice when we're having a hard time. In fact, they're likely catching some negative side effects, since we tend to take things out on our loved ones. Remember, you're doing this for them too. 

A good first step is to reframe therapy for yourself. "I think of seeing a therapist as just getting a second opinion about what you're doing," says Pahoua Yang, vice president of community mental health and wellness at the Amherst H. Wilder Foundation. "And then you can decide from there."

If you're concerned about privacy or disclosure, therapy is confidential. No one has to know! Licensed mental health professionals are bound by the law to protect your privacy. Unless someone is a threat to themselves or others, what goes on in therapy stays in therapy.

2. Find the right therapist — or type of therapy — for you.

Start by making a list of potential therapists. If you have medical coverage, your insurance company can help make that list for you. Ask the company for some nearby professionals who take your insurance. 

Psychology Today also has a database, which you can use to search for providers in your area, along with specialties, reviews and experience. 

Once you've identified a few potential therapists, reach out. Come up with some starter questions to ask when you interview them over the phone. What experience do they have working with your issue or community? How does a typical session with them work? Do their available hours match yours? 

Asking questions before a visit can help you know what to expect. But Gottlieb says the visit itself is the most important piece. "The reality is, you're not gonna know if it's the right fit until you're sitting in a room with that person," says Gottlieb. 

If transportation, access or motivation is a problem, online therapy like the app BetterHelp might be helpful. You can also ask to do Skype sessions, but make sure the therapist is licensed in your state. Otherwise, the therapist can't legally treat you. 

Not insured? Or on a tight budget? Look up a local clinic at a hospital or university where you can get low- to no-cost therapy with a therapist in training. 

That's actually how Gottlieb got her start as a therapist. "I trained at a clinic where people came in for no fee or a very low fee," she says. "I was supervised by licensed clinicians. That's also a great way to get help."

Don't feel ashamed or shorted by the idea of low-cost therapy. Gottlieb says clinic sessions actually have an advantage over pricier options. 

"In fact, you probably have more supervision than a private-practice clinician does, because when you're training, you have several sessions a week of supervision, so your case gets a lot of attention when you're in a clinic."

Group therapy can also be a great low-cost option. Group sessions tend to be relatively affordable compared with one-on-one sessions — sometimes even free. 

Open Path Collective offers a network of therapists who charge $30 to $60 a session. And some professionals price their sessions on a sliding scale fee, meaning their rates vary based on a customer's ability to pay. If you can't afford your preferred professional's rates, it's worth asking if sliding scale payments are an option at the therapist's practice.

3. It's OK to move on to a different therapist, or kind of therapy, altogether.

If your current therapist doesn't feel like a good fit, it's fine to "break up" with the person. 

"You want to make sure you find somebody who actually feels like they get you," says Joy Harden Bradford, Ph.D., host of the podcast Therapy for Black Girls. "It's OK to say, 'Hey, I think I may need something else' and to try to find another therapist who's going to be a better fit for you."

But after all that work of getting into therapy, it might feel daunting to dump someone and start over. 

Harden Bradford understands. She says it's important to push through that uncomfortable conversation and find something that works for you. Plus, she says, the therapist likely isn't going to be mad at you. 

"It is a part of our training, and we know that kind of thing happens," she says. 

Mental health professionals want you to get better, even if it's not in their care. Your current therapist might even be able to help identify a colleague who would fit better.

4. If you're comfortable with it, talk about therapy with others.

If you're already in therapy, and you feel comfortable, be open about it. 

John Kim, also known as The Angry Therapist, says he found an online following when he opened up about his divorce and his own mental health treatment. 

"I would share ... all the revelations I'm having about myself," says Kim. "And how much that's helping my relationships at work, at home ... and all of that happened because of me starting therapy." 

Kim says he wishes more people were open about going to therapy. He wants to see it normalized and encourages working it into conversation. 

Just keep it subtle. No need to share details. Simply let others know that you're prioritizing your mental health.

But Kim says it's important to remember that if you're sharing because you think someone else needs mental health support, it's best to show, not tell. 

"The best way to get someone in therapy is by example ... doing therapy and living a different way where they notice. To tell someone to go to therapy, that's not gonna land well."

Breaking down a stigma takes time. By talking openly about therapy and demonstrating its benefits, you just may inspire someone else to try it out.

Season Affective Disorder and What You Need to Know

Seasonal Affective Disorder (SAD) is a type of depression that comes and goes with the seasons, typically starting in the late fall and early winter and going away during the spring and summer. Depressive episodes linked to the summer can occur, but are much less common than winter episodes of SAD.

Signs and Symptoms

Seasonal Affective Disorder (SAD) is not considered as a separate disorder. It is a type of depression displaying a recurring seasonal pattern. To be diagnosed with SAD, people must meet full criteria for major depression coinciding with specific seasons (appearing in the winter or summer months) for at least 2 years. Seasonal depressions must be much more frequent than any non-seasonal depressions.

Symptoms of Major Depression

  • Feeling depressed most of the day, nearly every day

  • Feeling hopeless or worthless

  • Having low energy

  • Losing interest in activities you once enjoyed

  • Having problems with sleep

  • Experiencing changes in your appetite or weight

  • Feeling sluggish or agitated

  • Having difficulty concentrating

  • Having frequent thoughts of death or suicide.

Symptoms of the Winter Pattern of SAD include:

  • Having low energy

  • Hypersomnia

  • Overeating

  • Weight gain

  • Craving for carbohydrates

  • Social withdrawal (feel like “hibernating”)

Symptoms of the less frequently occurring summer seasonal affective disorder include:

  • Poor appetite with associated weight loss

  • Insomnia

  • Agitation

  • Restlessness

  • Anxiety

  • Episodes of violent behavior

Risk Factors

Attributes that may increase your risk of SAD include:

  • Being female. SAD is diagnosed four times more often in women than men.

  • Living far from the equator. SAD is more frequent in people who live far north or south of the equator. For example, 1 percent of those who live in Florida and 9 percent of those who live in New England or Alaska suffer from SAD.

  • Family history. People with a family history of other types of depression are more likely to develop SAD than people who do not have a family history of depression.

  • Having depression or bipolar disorder. The symptoms of depression may worsen with the seasons if you have one of these conditions (but SAD is diagnosed only if seasonal depressions are the most common).

  • Younger Age. Younger adults have a higher risk of SAD than older adults. SAD has been reported even in children and teens.

The causes of SAD are unknown, but research has found some biological clues: 

  • People with SAD may have trouble regulating one of the key neurotransmitters involved in mood, serotonin. One study found that people with SAD have 5 percent more serotonin transporter protein in winter months than summer months. Higher serotonin transporter protein leaves less serotonin available at the synapse because the function of the transporter is to recycle neurotransmitter back into the pre-synaptic neuron.

  • People with SAD may overproduce the hormone melatonin.Darkness increases production of melatonin, which regulates sleep. As winter days become shorter, melatonin production increases, leaving people with SAD to feel sleepier and more lethargic, often with delayed circadian rhythms.

  • People with SAD also may produce less Vitamin D. Vitamin D is believed to play a role in serotonin activity. Vitamin D insufficiency may be associated with clinically significant depression symptoms.

Treatments and Therapies

There are four major types of treatment for SAD:

  • Medication

  • Light therapy

  • Psychotherapy

  • Vitamin D

 These may be used alone or in combination.

Medication

Selective Serotonin Reuptake Inhibitors (SSRIs) are used to treat SAD. The FDA has also approved the use of bupropion, another type of antidepressant, for treating SAD.

As with other medications, there are side effects to SSRIs. Talk to your doctor about the possible risks of using this medication for your condition. You may need to try several different antidepressant medications before finding the one that improves your symptoms without causing problematic side effects. For basic information about SSRIs and other mental health medications, visit NIMH’s Medications webpage. Check the FDA’s website for the latest information on warnings, patient medication guides, or newly approved medications.

Light Therapy

Light therapy has been a mainstay of treatment for SAD since the 1980s. The idea behind light therapy is to replace the diminished sunshine of the fall and winter months using daily exposure to bright, artificial light. Symptoms of SAD may be relieved by sitting in front of a light box first thing in the morning, on a daily basis from the early fall until spring. Most typically, light boxes filter out the ultraviolet rays and require 20-60 minutes of exposure to 10,000 lux of cool-white fluorescent light, an amount that is about 20 times greater than ordinary indoor lighting.

Psychotherapy

Cognitive behavioral therapy (CBT) is type of psychotherapy that is effective for SAD. Traditional cognitive behavioral therapy has been adapted for use with SAD (CBT-SAD). CBT-SAD relies on basic techniques of CBT such as identifying negative thoughts and replacing them with more positive thoughts along with a technique called behavioral activation. Behavioral activation seeks to help the person identify activities that are engaging and pleasurable, whether indoors or outdoors, to improve coping with winter.

Vitamin D

At present, vitamin D supplementation by itself is not regarded as an effective SAD treatment. The reason behind its use is that low blood levels of vitamin D were found in people with SAD. The low levels are usually due to insufficient dietary intake or insufficient exposure to sunshine. However, the evidence for its use has been mixed. While some studies suggest vitamin D supplementation may be as effective as light therapy, others found vitamin D had no effect.

Join a Study

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions, including seasonal affective disorder. During clinical trials, treatments might be new drugs or new combinations of drugs, new psychotherapies or devices, or new ways to use existing treatments. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individual participants may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Please Note: Decisions about whether to apply for a clinical trial and which ones are best suited for a given individual are best made in collaboration with your licensed health professional.

Clinical Trials at NIMH/NIH

Scientists at the NIMH campus conduct research on numerous areas of study, including cognition, genetics, epidemiology, and psychiatry. The studies take place at the NIH Clinical Center in Bethesda, Maryland and usually require regular visits. After an initial phone interview to see if any of the clinical trials recruiting subjects are a good match for you, you will come to an appointment at the clinic and meet with a clinician. Visit the NIMH Clinical Trials — Participants or Join a Study for more information.

How Do I Find a Clinical Trial Near Me?

To find a clinical trial near you, you can visit ClinicalTrials.gov. This is a searchable registry and results database of federally and privately supported clinical trials conducted in the United States and around the world. ClinicalTrials.gov gives you information about a trial's purpose, who may participate, locations, and contact information for more details. This information should be used in conjunction with advice from your health provider.

Learn More

Free Booklets and Brochures

You can download or order free copies of the following booklets and brochures in English or en Español:

  • Depression: What You Need to Know: This booklet contains information on depression (depressive disorder or clinical depression), including signs and symptoms, treatment and support options, and a listing of additional resources.

  • Depression: This brochure describes the two most common types of depression: major depression, and persistent depressive disorder. It lists symptoms, treatment options, and how the condition may look different in women, men, seniors, and children.

  • Teen Depression: This flier for teens describes depression and how it differs from regular sadness. It also describes symptoms, causes, and treatments, with information on getting help and coping.

Federal Resources

Research and Statistics

Millennials Are the Therapy Generation

People in their 20s and 30s seek mental-health help more often, and they are changing the nature of treatment

Kristina, a 27-year-old publicist living in Manhattan, has been in and out of therapy since she was 9, when her parents got divorced. Back then, she says, “I had a pretty pragmatic view of what was happening, and so did my parents—going to therapy was just something you make kids of divorce do.” During her first year of college, Kristina (who requested that only her first name be used) suffered a sexual assault. Again, she says, therapy afterward was a given. “I figured I would use therapy to get through my trauma and then be done,” she says. “I eventually learned that’s not really how it works.” She has had four or five different therapists since then. So have most of her friends.

The stigma traditionally attached to psychotherapy has largely dissolved in the new generation of patients seeking treatment. Raised by parents who openly went to therapy themselves and who sent their children as well, today’s 20- and 30-somethings turn to therapy sooner and with fewer reservations than young people did in previous eras. 

According to a 2017 report from the Center for Collegiate Mental Health at Penn State University, which compiled data from 147 colleges and universities, the number of students seeking mental-health help increased from 2011 to 2016 at five times the rate of new students starting college. A 2018 report from the Blue Cross Blue Shield Association found a 47% increase between 2013 and 2016 in depression diagnoses among 18-to-34 year-olds; the report attributed the rise largely to the fact that far more young adults are seeking help.

“Many of my clients joke that they and their co-workers often start conversations with, ‘My therapist thinks…’” says Elizabeth Cohen, a clinical psychologist in Manhattan, “The shame of needing help has been transformed to a pride in getting outside advice.”

One reason for the shift is celebrities such as Demi Lovato, Lady Gaga and Dwayne (“the Rock”) Johnson, who have publicly discussed their struggles with depression. Many therapists also credit social media—often criticized as a source of millennial distress—with helping to normalize mental illness and to remove any lingering stigma from seeking support. Vix Meldrew, 32, a London blogger, says that whenever she talks about mental health online, her response from readers skyrockets because she is “making them feel less alone.”

‘I think the therapist’s natural instinct to listen and not give advice can be challenging and threatening to millennials.’

Many younger people pursue therapy as another form of self-improvement and personal growth, not unlike yoga, meditation or “preventive Botox.” (A 2015 survey by the research firm Field Agent found that millennials spend $300 a month on such pursuits.) Some millennials also use life coaches. That includes Ali Wunderman, a 29-year-old freelance journalist in Whitefish, Mont. “My life coaching and my therapy work really well together,” she says. “It’s about forming habits and behaviors that lead to a fuller life.”

But young people are struggling to find such balance. A 2018 study of 40,000 American, Canadian and British college students published in the journal Psychological Bulletin found that millennials are suffering from “multidimensional perfectionism” in many areas of their lives, setting unrealistically high expectations and feeling hurt when they fall short. This propensity can motivate them to seek assistance when something goes wrong—but it also sometimes drives them to turn that assistance into dependence. 

Some young people think “that the therapist is going to provide an answer rather than help them discover the answer within themselves,” says Dr. Cohen, the Manhattan psychologist. Dr. Cohen recalls one recent 20-something client who was unsure about whether to stay in a relationship. “It really felt like she had gone from therapist to therapist looking for one that would tell her what to do,” says Dr. Cohen. “I think the therapist’s natural instinct to listen and not give advice can be challenging and threatening to millennials.”

Technology has contributed to the expectation of a quick fix. Apps and online services such as Talkspace and MyTherapist offer therapy by phone, chat, video and message board, making it more likely that young people will opt for superficial bromides over meaningful long-term help. Used correctly, however, tech-based therapies can fill in important gaps, especially for millennials more comfortable facing their devices than a therapist. Julia Koerwer, 28, a graduate student in social work in Queens, N.Y., uses textlines when she needs immediate help. “People tend to think crisis hotlines are for suicide only,” she says. “But just to be like, ‘OK, it’s Wednesday, I see my therapist on Sunday, and I feel like [expletive] right now. What can I do?’ That’s helpful.”

New studies also show that young couples are using therapy before moving in together or in the early years of marriage—something virtually unheard-of in earlier generations. Kristina and her partner started couples counseling in 2017 when they got their first apartment together. “If my mom and stepdad weren’t communicating well, they’d be like, ‘Oh, let’s just talk about it over dinner,’” she says. “But we work late, and then at home we’re answering emails on our phones, and talking it out over dinner just doesn’t work that way anymore.” 

For many, such “self-care” doesn’t feel like a chore. “I just enjoy therapy,” says Ms. Koerwer. “I don’t enjoy getting blood drawn—I’d be looking for ways to stop having to do something like that. But I like my therapist, I have a good relationship with him. It’s not like I’m trying to figure out, at what point can I stop doing this?”

Check Out Change Counseling’s Updated Services

Check out our updated services page with new and innovative interventions to help you in your healing process!

SPECIALIZED INTERVENTIONS

  • ACCELERATED RESOLUTION THERAPY

    • ART incorporates a combination of techniques used in many other traditional psychotherapies. ARTworks directly to reprogram the way in which distressing memories and images are stored in the brain so that they no longer trigger strong physical and emotional reactions. ART accomplishes this through the use of rapid eye movements similar to eye movements that occur during dreaming. Although techniques similar to these are used in other types of therapies. ART’s very specific and directive approach can achieve rapid recovery from symptoms and reactions that may have been present for many years. ART combines long respected, sound treatment practices with safe and effective methods validated by current scientific research studies conducted by the University of South Florida. Find out more here.

  • EQUINE THERAPY

    • Equine Therapy (also referred to as Horse Therapy, Equine-Assisted Therapy, and Equine-Assisted Psychotherapy) is a form of experiential therapy that involves interactions between patients and horse. It involves activities (such as grooming, feeding, haltering and leading a horse) that are supervised by a mental health professional, often with the support of a horse professional. The goal of equine therapy is to help the patient develop needed skills and attributes, such as accountability, responsibility, self-confidence, problem-solving skills, and self-control. Equine therapy also provides an innovative milieu in which the therapist and the client can identify and address a range of emotional and behavioral improvements. Check out an informational article here.

  • CANINE THERAPY

    • Canine-assisted therapy uses dogs to promote health and healing. Like other animals, dogs are accepting, comforting and non-judgmental, making them ideal therapy companions. In canine therapy, patients may: learn to give a dog commands, walk and play with a dog, or pet and care for a dog. Canine therapy can be immensely healing. Children and teens respond particularly well to canine therapy, developing trust and strong bonds with the animals. Many find it easier to open up and talk when the focus is on the dog. The therapist working with the patient can gain valuable insights by observing the interactions between patients and their canine companions. More info here.

  • ECO THERAPY

    • Ecotherapy is based on the idea that people are connected to and impacted by the natural environment. It can consist of walking, hiking, cycling or meditating in nature. Ecotherapy can be especially beneficial for those with depression, anxiety, stress or other emotional issues. Read more about its benefits here.

  • TELE-COUNSELING

    • Video counseling provides behavioral health therapy in the privacy of your own home. It allows greater flexibility for clients who travel for work, have changing schedules not always allowing for consistent in-person sessions, identify transportation as a barrier to care, and more! It is 100% HIPPA compliant and in many cases provides more privacy than traditional in-person therapy. More about virtual therapy here.