Reaching Out for Help

Frisco is a great place to live, by almost any standard of measure. Exemplary schools, robust economic growth, vibrant churches, an abundance of family-friendly recreational activities and safe neighborhoods all add appeal to the shiny newness of an affluent city that seemingly burst on the scene out of obscurity little more than a decade ago. At first glance, one could easily surmise that everyone in this exurban neck of the woods is uniformly healthy, wealthy and happy. What’s not to be happy about, after all? The reality, however, is the material comfort and relative affluence of Frisco’s residents doesn’t shield them from anxiety and depression, maladies that affect scores of people all across the nation, from every walk of life.

Dr. David Tharp has been practicing psychiatry since 1979 and has been the medical director of Frisco’s Stonebriar Psychiatric Services since he founded the clinic in 2004. As an expert in dealing with disorders associated with anxiety and depression, he says one of the most surprising things about anxiety and depression is how widespread they are. “Both anxiety and depression are extraordinarily common,” says Dr. Tharp. “Some studies have indicated that by the end of this decade, depression will count for the second-largest functioning disability in the world, behind heart disease. Other studies have indicated that almost 40 to 50 percent of people will experience some episode of depression in their lifetime.” While Dr. Tharp notes that depression and anxiety often go hand-in-hand, he says they don’t necessarily have to. And while people suffer from depression and anxiety year-round, there are some who experience the symptoms more acutely during the winter months. “There is a specific type of depression called Seasonal Affective Disorder, which is primarily in the fall and winter. And the holidays represent a very stressful time for many people, certainly,” he says.

When it comes to depression, Dr. Tharp says the symptoms for some sufferers may have been present for so long they are unable to even identify the condition. “Depression usually has folks feeling sad and it’s hard for them to find enjoyment where they normally might. Frequently it’s just a lack of pleasure or joy in life. You can have depression that’s associated with being very agitated, nervous and tense, or you can have a depression that manifests as lack of energy or no motivation, where it’s hard to get out of bed at times.” While sleep may be affected because of depression, Dr. Tharp says some sufferers will experience insomnia while others may sleep too much. Appetite may also be affected by depression, again at both extremes, either by eating too much or not enough.

Anxiety, says Dr. Tharp, is more difficult to define than depression. “Anxiety is a state of not being able to relax; feeling tense, nervous or worried much of the time. It can go from there all the way to panic attacks, which are not just higher levels of anxiety; they’re almost a different phenomenon. That’s when all of a sudden, out of the blue, you feel terrified. There’s no reason for it that you’re aware of. Most people who have (a panic attack) think they’re either having a heart attack or going crazy, and the first time it happens people will frequently end up in the emergency room.” While a panic attack is not as common an occurrence on the spectrum of anxiety, Dr. Tharp says all humans experience some level of anxiety as a result of life’s stresses. “Anxiety is not an uncommon phenomenon in the world today. You can have anxiety as a normal human emotion when you feel things are not under your control, but that’s different from the anxiety one might have as a diagnosis.”

While depression and anxiety are widespread conditions, Dr. Tharp says far too often people are slow to seek out help. “I think a lot of people still see (getting help) as a sign of weakness,” he says. “Maybe not as much as they used to, but still there’s a feeling in many people that they ought to be able to pull themselves up by their bootstraps and get through it. That’s not realistic. It’s not a matter of willpower. There’s a very real physiological part to it, which you can see demonstrated in PET (positron emission tomography) scans. A normal brain has many lit-up areas where it’s very active. In the brain of someone who’s depressed, it’s not nearly as active and lit-up. I think a lot of people don’t realize that, and they think somehow it’s just their feelings, they’re too emotional or they ought to be able to handle it somehow.”

In terms of seasonal depression, Dr. Tharp says unrealistic expectations often play a significant role. “It’s a tough time of year. The holidays are not always a happy time for people. Sometimes people can get themselves depressed because their expectations of what should be happening for Christmas or at the holidays is not realistic.” While it’s true for some people, the holidays trigger unhappy memories of family dysfunction or childhood abuse, others who experience seasonal depression may have had the opposite experience. “Some people have very good memories, but as we get older it’s hard to recapture the magic of when you were a kid having Christmas. I think, especially now, one of the difficulties is people expect so much of themselves. If they can’t get their kids the latest iPhone, for example, they feel like they’ve failed as a parent. The economy has put a lot of stress on many people, and there are many factors we can’t control. So if people can’t fulfill what they think are the expectations of others, they can get very depressed about that. The holidays can be a very stressful time for many people, whether it has to do with gift-giving, or even the stress of having a lot of family being around.”

Depression may also manifest itself as seasonal affective disorder, a mood disorder that affects some people only during certain seasons of the year. While not as common in the warmer climate of Texas, Dr. Tharp says seasonal affective disorder can have a significant effect on those who suffer from it. “Seasonal affective disorder tends to start coming on around mid-to-late fall and generally lasts through the winter, then gets better in the spring. We know it has something to do with the length of the days in terms of daylight, so it tends to be worse up north where the days are even shorter than they are here in the south.”

One treatment that has proven helpful for many who suffer from seasonal affective disorder, says Dr. Tharp, is phototherapy. “Phototherapy is basically exposure for about an hour a day, preferably early in the morning, to natural spectrum light of at least 10,000 lumens.” Dr. Tharp explains that part of the treatment of phototherapy involves the patient periodically glancing directly at the light, and it’s partly the effect of the light hitting the retina of the eye that triggers certain circadian rhythms, making up for lost sunlight exposure and resetting the body’s internal clock. “Phototherapy frequently is very helpful for those who have seasonal affective disorder, but it can also be helpful for those who have a major depressive disorder that happens to get worse on a seasonal basis. It’s a treatment that can be added for those folks, as opposed to raising their medication, for example.”

Another treatment option for depression that has been FDA-approved, transcranial magnetic stimulation (TMS), has been available for four or five years, but mostly in large treatment centers like Johns Hopkins or the Mayo Clinic. Now available on a more widespread, local level, Dr. Tharp says TMS is one treatment option that is available to patients of Stonebriar Psychiatric Services. “One of the things we know is that the sooner people respond to medication, the better the chance of response, meaning the more you have to try, the less likely you’re going to find something that works. TMS has been approved for people suffering from depression that hasn’t adequately responded to medication.” The treatment uses a rotating coil magnet, similar to an MRI (Magnetic Resonance Imaging), to generate a low electrical current. Dr. Tharp stresses that TMS is very different from electroconvulsive therapy, formerly known as “electroshock” treatment. Patients receiving the painless TMS procedure are awake for it’s entirety, even able to drive themselves to and from the office for treatment.

As to the question of when should a person seek out the help of a psychiatrist, Dr. Tharp says it generally should happen when depression or anxiety are affecting one’s function in a negative way. “Specifically, when it is to the point that there are physical symptoms such as significant sleep problems, appetite problems or there’s so little energy or motivation that it’s hard to get up and go to work. Or, in terms of anxiety, if a person is having panic attacks or experiencing anxiety to the degree that it’s difficult to stay at work or to carry out one’s functions at home. When those types of things are happening, it makes sense to see a psychiatrist. Many people start with their family doctor, who, percentage-wise, is probably the initial contact for the majority of depressive disorders. Often in those cases, medication can play a positive role in the treatment plan, but not to the exclusion of psychotherapy and counseling. I personally think, in most cases, those are extremely important.”

In the world of counseling, Rhett Smith has nearly two decades of experience as a licensed marriage and family therapist. From his Plano office, Mr. Smith often counsels people who are dealing with the effects of depression and anxiety, and agrees with Dr. Tharp that the prevalence of these disorders is undeniable. “All the statistics I’ve read in the last year or two say that somewhere between 18 to 20 percent of the population is or could be diagnosed with what would be considered an anxiety disorder. One of the things I’ve taken from these statistics is that these are just the numbers taken from those who sought help. So, if 18 to 20 percent of our population is diagnosed with an anxiety disorder, think of the sheer number of people who struggle with anxiety day-to-day who haven’t sought help. I want to encourage people that it is a prevalent issue, and the more that people talk about it and take the stigma out of it, the more helpful it will be for people in getting some success around it.”

One of the unique perspectives Mr. Smith brings to his practice is the idea that anxiety may actually be used in a person’s life as an opportunity for personal growth. In his book, The Anxious Christian (2011, Moody Publishers), Mr. Smith poses the question, ‘Can God use your anxiety for good?’ In explaining the book’s subtitle, Mr. Smith says, “In counseling, I try to get people to look at their anxiety and not ignore it. I do believe anxiety is really one of the best opportunities for growth in life. A metaphor I often use is to compare anxiety to the dashboard lights in a car. If you’re driving and a light comes on, it’s important to pay attention to the light, because if you don’t you’re going to end up on the side of the road, broken down in some way. In the same way, anxiety is an internal light that goes off inside of everybody. It basically says, ‘Pay close attention to what’s going on.’ I find that people often don’t want to do that. They prefer to bury their anxiety or sweep it under the rug. And that can have some ill effects, manifesting in anxiety disorders or eating disorders that can then lead to long-term depression. So I try to help them ask questions, like, ‘what is that anxiety saying to me? Is there something in my life worth paying attention to? Is there maybe a disconnect in my marriage? Is something wrong in my work situation? Am I not happy with the direction my life is going?’ I feel like we can use anxiety as a tool to explore what’s happening in life. It can be an early warning sign, so you want to pay attention and, as soon as possible, begin to ask questions about it.”

One hurdle Mr. Smith says often prevents people from facing their anxiety is shame, particularly among those who profess to be Christians. “People who go to church often have a view that anxiety is bad, and having anxiety makes you a bad person. They come into my office quoting Philippians 4:6 from the Bible, where Paul says, ‘Don’t be anxious about anything.’ But they take that verse out of context. I tell them Paul wrote those words after a long journey of being anxious about things. I try to bring freedom to people and encourage them that it’s okay if they’re anxious. Part of my job is to help people understand, and to encourage them to talk about it and get some healthy coping skills around their anxiety.”

When it comes to depression, Mr. Smith says misconceptions abound, particularly as it relates to men. While depression is often assumed a condition more prevalent among women, studies show a large number of men suffer with depression in silence. “A great book about men and depression is Terrence Real’s I Don’t Want To Talk About It,” says Mr. Smith. “In that book, he talks about how boys learn early on in our culture that it’s not safe to talk about how you feel; to be vulnerable and let your guard down. Around age 4 or 5 they start to receive messages from their mom, dad, coaches and friends like ‘grow up,’ ‘stop crying,’ ‘don’t be a wuss.’ Research has tracked that, over time, boys tend to stuff their emotions because it’s too risky to express them. So eventually, you have all these men who are older now, and haven’t figured out how to talk about how they feel. Many guys I deal with who are angry are actually depressed underneath. Their anger is the outward expression of those emotions when men feel they are stuck in life. In fact, one of the phrases that often comes up in conversations I have with men is, ‘I feel stuck.’ For me, that’s code for ‘I feel depressed.’”

Out of his own years of experience counseling men who are grappling with depression, Mr. Smith wrote the book What It Means To Be A Man (2013, Moody Publishers). “I think depression is a huge issue for men,” he says, “especially in our North Plano/Frisco culture where there’s a fear of failure or not keeping up. There’s a lot of pressure to succeed, especially from a financial perspective, and drive the right car and have everything that everyone else has. I find many men in our area struggle with feeling they’re not adequate enough, that they can’t keep up as a father or in their marriage. Depression among men is a very prevalent issue in our area.”

As part of his counseling process, Mr. Smith places a high emphasis on self-care. For those struggling with anxiety or depression, he says appropriate self-care may be an important first step toward wholeness. “One of the things I often say is that taking care of yourself is not about being selfish or indulging yourself. It is about taking care of yourself so that you have life to give to other people.” While he says he is not anti-medication by any means, Mr. Smith says people too often turn to medication as a first resort, when there are a host of other possible solutions to explore.

Within the realm of self-care, Mr. Smith emphasizes four main categories with his clients: physical, emotional, mental and spiritual. Through an assessment at the beginning of their counseling journey, Mr. Smith determines if clients are doing anything in each of those areas that may help alleviate their anxiety or depression. If not, he encourages them to choose one thing within each category they can begin to practice for 30 days, until it becomes a habit. “They don’t have to do it every day,” says Mr. Smith, “just enough so that each week they feel they have begun to build a rhythm into their life where they are taking care of themselves physically, emotionally, mentally and spiritually. It’s quite amazing the amount of depression and anxiety that lifts from people when they get out and, for example, start running or getting enough sleep or eating better; when they don’t feel alone and they’re spending time with a spouse or their friends; when they have a new hobby, or maybe they’re in a Bible study or taking yoga.”

Breathing exercises are another treatment Mr. Smith uses with clients who are grappling with anxiety. “Often when anxiety hits, people feel like they can’t breathe, or their breathing gets very shallow. I work on a routine with people so that, for example, every morning they might find a comfortable spot and practice focusing on their breathing for just two to three minutes. There’s no magic in it, nothing radical is necessarily going to happen. What it does is build a discipline of focusing on one’s breath. I call it a ‘fire drill,’ so when anxiety does hit, that person knows they can focus on their breathing work and focus on their body.” Mr. Smith says one of the techniques he teaching clients involves sitting still and focusing on clearing their minds as they breathe. “Any time an anxious thought comes, I teach them to bring the focus back to their breath, coming into the nostrils and leaving out of the mouth. It really helps the person stay grounded and deal with their anxiety.”

In addition to self-care and breathing exercises, Mr. Smith also emphasizes the importance of community to clients struggling with depression or anxiety. “I think people who struggle with anxiety and depression are often outside of a community. They may have a lot of friends or people they’re around, but they’re not in a community where they feel they are truly known or they belong.” Having other people who will listen and with whom one can identify, says Mr. Smith, is a critically important component to battling anxiety or depression. “Whether it’s a running club, a small group at church or a MOPS group, being part of a community is hugely important.”

One of the reasons dealing with anxiety and depression is so important, says Mr. Smith, is the potential impact it can have on other members of a family. “I tell people that when they feel anxiety and pay attention to it, that’s a healthy anxiety. Anxiety becomes unhealthy when it’s buried; it’s like a virus that tends to move itself around a family. I think it’s crucial as parents that we learn to manage our own anxiety. If I get a kid in my office that’s anxious, more than likely I’ll find a mom or dad who’s anxious. I really try to help families understand our inability to manage our own anxiety means we leave someone else to manage it for us. I see that a lot, in Frisco especially, where there’s a lot of pressure on families and kids to fit in and succeed. There’s a lot of high anxiety around that.”

As student assistance coordinator for Frisco Independent School District as well as a licensed professional counselor with a private practice in Plano, James Caldwell knows from his own daily interactions with Frisco students that anxiety and depression are a fact of life for many kids. “We know that in a given year, about 20 percent of kids will experience an emotional disorder in a strong enough way to be classified as diagnosable. Of those, about 33 percent are related to anxiety and about half as many are related to depression. Especially in our area, where you have a lot of affluence and kids who, for the most part, are high achievers, they start feeling like they’re not good enough. Even when they’re making great grades, we’ll see anxiety in kids from homes that have parental pressure. They get direct messages like, ‘If you want to get into a good college, you have to make great grades.’ Nowadays, parents can get online and check their kids’ grades daily, so grades are constantly there, always being talked about. Kids may start to feel like they are nothing but their performance. When they perform well, they feel good about themselves. But when they don’t hit the mark, they don’t feel good about themselves.

Another reason some kids in the Frisco area experience anxiety, says Mr. Caldwell, is a lack of connection. “Kids in Frisco are moving here from all over the country; even all over the world. I grew up in McKinney and lived there my whole life, so I knew everybody. I had Boy Scouts, church, a community of friends and a lot of support. That sense of belonging buffers trauma, so when a child goes through painful situations, they’re not huge. Many of today’s kids who have moved to Frisco feel disconnected and don’t know where to go for help. When people feel disconnected, they feel anxious, and we see a lot of that happening in little kids as well as middle school and high school kids.”

Well-intentioned parents may also unwittingly contribute to the anxiety or depression of their children by choosing to shield them from the normal, necessary struggles of life and by elevating the value of their child’s self-esteem over effort. Mr. Caldwell refers to research findings captured in the book Generation iY by Tim Elmore, saying, “We’ve raised up a generation of kids that has been taught that everyone is a winner. Everyone gets a trophy. We coddle and overprotect, not allowing our kids to struggle. Because of that, they don’t learn how to deal with problems.” Mr. Caldwell says when these kids reach middle school, they are often faced with the harsh reality that the things they’ve been told are not true. “They realize not everybody win — not everyone is going to like me. Things aren’t always going to be fair, and not everything is going to go my way. When this happens and they don’t have the stress management skills they need to cope, they act out in extreme ways.”

While it seems fundamental, Mr. Caldwell says part of helping kids cope with anxiety involves teaching them that stress is a normal part of life. “It’s important for kids to see adults have stress, and they see how we deal with it. It’s huge for kids to know their parents struggle and don’t necessarily know what to do all the time. That helps normalize feelings of stress for kids.” Mr. Caldwell acknowledges the delicate balance parents must find between letting kids see life is full of ups and downs while not increasing their anxiety by over-emphasizing life’s struggles. “We know anxiety can run in families,” Mr. Caldwell notes. “The mindset of some parents can lead kids to become really fearful. Another thing to avoid with younger kids is pulling them out of things when they’re experiencing anxiety. As parents, we can become fearful and try to insulate our kids, keeping them under lock and key. Then, they never have the chance to get over their fear. Many times with younger kids, the only way to get over anxiety is to get in there and face your fear. So, for example, if your child is afraid of people and you homeschool them and keep them in the house all the time, there’s no real way for them to get over that fear.”

Another important step for parents that can greatly reduce anxiety in their children from a very young age is the avoidance of equating their child’s identity with their performance. “On the prevention side of things,” says Mr. Caldwell, “it helps if parents will not use adjectives to describe their kids behavior, and use adverbs instead. So when a child gets a good grade on their math test, instead of saying, ‘You’re so smart,’ say, ‘I notice you worked hard on your math homework. It looks like it’s paying off for you.’ We want kids to see they’re getting positive results because of what they’re doing, not who they are. When we tell kids they’re achieving because they’re smart or they’re good, then when they don’t achieve, what they conclude is they’re not smart and they’re not good. When we can avoid labeling kids with adjectives, we’ll see less perfectionist thinking out of kids.”

For parents dealing with a child’s anxiety or depression, Mr. Caldwell encourages collaboration with their school counselor in order to maximize the child’s progress. “A lot of parents think that if their child gets a diagnosis of depression, for example, and they tell the school counselor, that information will somehow be broadcast all over the school, and it simply isn’t. That’s an extremely confidential thing. But many times, we’ll have parents who get a diagnosis for their child — it could be anxiety, depression or even schizophrenia — and they won’t tell (the school) because they’re afraid it will go on some kind of record. That information doesn’t go on any kind of record, it just helps the school to work with them. If the parents want us to, we can even work with the child’s outside therapist. There are tremendous amounts of help available here in our community that parents don’t use. There’s free counseling we can set parents up with through a couple of programs we have. I and another LPC for the district can see kids at school, and this is all private and confidential, it’s not anything anyone else knows about. We’re so lucky in Frisco to have these types of programs to help kids, but they’re so often not utilized.”

Ultimately, whether young or old, reaching out for help is often the turning point in a person’s battle with anxiety or depression. Too often, though, the decision to seek help happens after anxiety or depression has already taken a heavy toll. Says Rhett Smith, “Getting help through counseling can be a huge commitment of your time, energy and resources, so people tend to wait for that. Usually, what drives people to seek help is that life is falling apart. That’s not everybody, but often it tends to be the case. Something externally has to happen, like a spouse has to file for divorce, their kid has to get kicked out of school or they have to have their job fall apart. I think that’s unfortunate, because people feel something is not right earlier on, but they wait longer to get help either because they think they can fix it on their own, or maybe they don’t know how to reach out and what tools are available to them. I always tell people, at the first sign that something is going wrong, reach out and get some help. You put yourself in a huge position to have the opportunity to nip that in the bud, whatever it is, and to really grow from it.”

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