Category Archives: Depression


REBT: The Elegant Solution

Cognitive Behavior Therapy: REBT, The Elegant Solution

Cognitive Behavioral Therapy (CBT) is a term bandied around a lot in news stories or any conversation about therapy. There is a lot of scientific support for its efficacy in treating issues such as Obsessive Compulsive Disorder (OCD), Post-traumatic Stress Disorder (PTSD), unipolar depression, anger, and bulimia. But there is still not perfect consensus among researchers, theorists, and clinicians about what exactly CBT is and what it isn’t. While some disagreements are about whether or not cognitive changes or learning principles (behavioral) are responsible for someone with depression feeling less depressed, some of the confusion is simply due to the variety of cognitive behavioral treatments.
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Robin Williams

Robin Williams’ Full Life

Robin Williams

I am not sure anyone would have predicted how many thoughts and feelings of so many people would be dedicated to the loss of Robin Williams. Personally, I found myself thinking about it during a morning jog, and the rest of that day. I wondered what clients of mine and everyone else would think about someone probably considered by most of us as incredibly successful, loved, rich, fortunate, and funny taking his own life. How would we make sense of it? Would there be judgment? Would people sympathize or empathize? Would people not at all be able to connect to someone seemingly having so much of what some of us long for and still suffering enough to choose to end his life? Or would this passing not have much of an impact?

It turns out my clients and, it seems Americans in general, have been spending considerable time reflecting on the passing. I was astounded how much his passing affected the national consciousness. I was also touched by the gentleness expressed in so many posts online about how his work had brought enjoyment and how much sympathy fans had for him and his family.

Initially as I ran that morning, I imagined writing about suicide and how difficult it is for many if us to truly imagine suffering so great we would do almost anything to make it stop. Hoping that with greater understanding more people could bring support to those in need and perhaps create policies and fund research to aid treatment efficacy. Originally I thought I would list some of the predictors of suicide, explain how the primary psychological mechanism was responsible, and discuss which treatments could be preventative, and how there are still people we can’t reach. I planned on explaining that many people who could be helped aren’t and there is still a group of people who receive treatment for which it isn’t effective and that these are the reasons we need more research and more open dialogues about this too common tragic end.

But as I listened to people talk about Robin Williams and as I read about him, about all of the other days of his life- not his last one, about all of his other behaviors; all of his other choices seemed so incredibly important.

While I can never know what his experiences were, it seems likely from much of what he shared publicly, even mentioning details in his stand-up acts, that he battled addiction. I don’t claim to know what or even if he had other diagnoses, but I imagine that there was considerable emotional and psychological pain that often accompany addiction issues.

But with that internal pain, there were still so many days, performances, and interactions. What became clear as I remembered movies of his I had seen, and discovered as I talked to people, was that in part so many people were so moved by someone they didn’t know because of the sheer magnitude of his contribution to our memories- he was prolific. His performances were not only Oscar worthy- but they were frequent – he gave tons of performances for children, adults- for everyone. There is no doubt there had to be many days he didn’t feel like it. Yet he gave.

I have found myself many times quoting his Scottish golf bit from one of his performances. In fact, in between finishing that last sentence and this one, I went and watched it again- his performances are that enjoyable. And who won’t laugh while watching Mrs. Doubtfire or laugh and fight back tears watching Good Morning Vietnam? So many days he gave performances- and probably carried emotional pain and psychological conflict with him, even on some of those days. We all benefitted from those choices, our lives have been richer because of those choices- hopefully his life was richer from choosing to work and persist too.

Psychological Pain and Values

Maybe his suffering was far greater than many of ours- we can never know. What I do believe is that as humans, we all carry the capacity to suffer intense psychological pain, and if you can’t imagine that, please consider yourself fortunate. I also believe his great body of work is a testament to what one can do, acting even while carrying pain, instead of waiting for all pain to cease- valuing what is most important, persisting, and persevering. He gave performances that moved us, entertained us, and will continue to do so for generations to come.

His wife, Susan Schneider, said “As he is remembered, it is our hope the focus will not be on Robin’s death, but on the countless moments of joy and laughter he gave to millions.” While it may seem impossible not to think of his death, if anyone can make us forget about pain and loss, Robin Williams may be the guy. I’ve said many times that I believe humor to be a potent therapeutic tool. In fact, it seems laughter in therapy sessions is typically a very good prognostic indicator from my standpoint. He gave us laughter and joy- what gifts. Those gifts could be enough to make us appreciate him- but as I read there was more. Outside of professional life, and apparently many times outside of the public eye, he gave in other ways.

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I heard an amazing anecdote that may give those of us who didn’t know him an idea of what he found important. Jessica Cole, a young girl, diagnosed with brain cancer, had been granted her dying wish, to meet her hero, Robin Williams. Unfortunately, she became too weak and was not going to be able handle the long flight. After hearing that, Robin Williams paid for his own chartered flight to go to her. Other stories have surfaced as well- all indicating other ways he connected to people outside of acting and stand up comedy.

He will surely be missed by his family and friends. He will also be missed by the rest of us whose lives were enriched by his work- choosing on so many days to give his best. Perhaps we can also benefit by recognizing and emulating the behaviors in his life that were dedicated to values like compassion, connection, and generosity.

At times we may hope with the next achievement or insight we will discover the life without the dark shadow, the sky without storm clouds, the emotional life free of bad feelings- but are any of us ever free of that? Perhaps that too is why this particular loss, the death of a man that brought us such joy and laughter doesn’t make sense to us. How could he have elicited so much joy and appeared so energetic and ebullient- while at times suffering underneath to such an extent? I hope we can all open up to the possibility that meaningful work and satisfying lives may not be free from emotional pain. Robin Williams most certainly had emotional pain in his life and struggled, and for so many years continued to work, connecting us to him, and to each other. We can all learn from choices like that.

As always Kahlil Gibran gives a perspective that may elucidate some of these issues.

On Joy and Sorrow

By Kahlil Gibran

Your joy is your sorrow unmasked.
And the selfsame well from which your laughter rises was oftentimes filled with your tears.
And how else can it be?
The deeper that sorrow carves into your being, the more joy you can contain.
Is not the cup that holds your wine the very cup that was burned in the potter’s oven?
And is not the lute that soothes your spirit, the very wood that was hollowed with knives?
When you are joyous, look deep into your heart and you shall find it is only that which has given you sorrow that is giving you joy.
When you are sorrowful look again in your heart, and you shall see that in truth you are weeping for that which has been your delight.

Some of you say, “Joy is greater than sorrow,” and others say, “Nay, sorrow is the greater.”
But I say unto you, they are inseparable.
Together they come, and when one sits, alone with you at your board, remember that the other is asleep upon your bed.

Verily you are suspended like scales between your sorrow and your joy.
Only when you are empty are you at standstill and balanced.
When the treasure-keeper lifts you to weigh his gold and his silver, needs must your joy or your sorrow rise or fall.

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Coffee’s Health Benefits

Coffee is Good for You

Whether America runs on Dunkin’ or Starbucks can be debated. But there is no question that many Americans start their day with coffee.  There are plenty of marketing campaigns aimed at getting us to consume the stuff – “The best part of waking up is Folger’s in your cup.”  Once again, the brand aside, for many it probably does feel like the best part of the morning because of all coffee contains.

We don’t yet understand the precise role of all of the ingredients in terms of health benefits.  What we do know is that coffee contains numerous substances and it has been associated with health benefits, e.g., reducing depression, prostate cancer, stroke, and Type 2 Diabetes.  What we don’t know for sure is exactly which of the substances are related to which benefits, and if any of the short-term changes like increases in blood pressure, insulin, and homocysteine are problematic.  But let’s look at a little of what we do know about coffee.  Just what is in that cup of Joe?


First, coffee contains caffeine which is a powerful psychoactive drug that helps many of us see coffee as the best part of waking up.  An average eight ounce cup contains around 100 mg of caffeine.  Caffeine can increase attention, wakefulness, and overall performance.  Of course if the levels become too high it can decrease performance, and cause or exacerbate all kinds of problems like anxiety, irritability, and insomnia.

Caffeine is a stimulant and coffee consumption is where the majority of Americans get their caffeine.  There are of course other beverages that contain caffeine like tea and the growing number of “energy drinks.”  The caffeine in coffee, like other stimulants, is likely the culprit for raising blood pressure soon after coffee consumption.  But, for regular coffee drinkers this effect likely diminishes.  And as we will see, coffee has been associated with benefits that reduce cardiovascular risk factors.  Even decaffeinated coffee has been found to improve some health outcomes, which indicates other substances in coffee may be of interest to healthy minded individuals.


Diterpines are typically known for their anti-inflammatory properties.  Normally I encourage my healthy patients to eat or do anything that reduces inflammation and regularly incorporate it into their lifestyle program (of course if there is a medical issue, I make sure they know to run it past the appropriate physician).  Coffee’s diterpines may present ambivalence for some medical professionals.  Cafestol and kahweol are two diterpines found in coffee.  These two may be responsible for findings that coffee can reduce problems with liver disease.  Paper filters (and there is some evidence mesh screens as well) remove the majority of these diterpines.  So the effect of cafestol and kahweol will be for unfiltered coffees.  If research on their impact on liver disease becomes more conclusive that could be a reason to drink more unfiltered coffee, especially if liver disease is something you may be at risk for developing.  But a study in the American Journal of Epidemiology indicates that unfiltered coffee increases LDL (low-density lipoproteins).  While there is debate about the count, size, or LDL at all as a predictor of heart disease, it is not settled science.  So if you are a coffee drinker and have concerns about liver disease and/or your LDL, having a conversation with your physician may be a logical step.  You may simply want to begin using or doing away with your paper filters which soak up most of the cafestol and kahweol depending on whether you are targeting liver disease or LDL.


Coffee also contains an important antioxidant, chlorogenic acid.  Antioxidants stop the damaging effects of free radicals that put us at risk for certain cancers.  So in general antioxidants are good for increasing the quality and lengths of our lives.  But chlorogenic acid has also been associated with inhibiting glucose absorption and stabilizing insulin levels.  This antioxidant may be responsible, at least in part, for the dramatic findings that coffee may prevent Type 2 Diabetes.  Once again there may be a caveat.  It has also been associated with raising the levels of something correlated with heart disease, homocysteine.  But as we see later on, the effect may not have a significant impact.

Cup of Joe or No Joe?

Caffeine, diterpines, and chlorogenic acid have all been associated with some negative markers, e.g., increased blood pressure, homocysteine levels.  Given that, it certainly makes sense to speak to your physician about his or her take on the relative risks and benefits of coffee given your particular genetics (some of us metabolize coffee differently), risk-factors, and lifestyle.

With that said, what may be more critical for your physician and you to discuss than the associated markers, are findings from larger scale prospective disease studies.  While markers may be important- the reason we use them at all is in hopes of discovering how they are linked to endpoints like disease or quality of life.  Studies conducted in the U.S., Europe, and Japan have all indicated that coffee appears to reduce the risk of Type 2 diabetes- which is one of the fastest growing health problems facing Americans and people worldwide.  Diabetes also puts your heart health in jeopardy- so doing what we can to prevent it has to be a health priority. Heart disease is the number one killer of men and women.  These studies followed thousands of individuals over years and controlled for many confounding variables that earlier studies had not included, e.g., alcohol consumption, cigarette smoking, and a sedentary lifestyle.  The support for coffee’s role in Type 2 diabetes appears to be quite significant.

Preliminary evidence indicates that coffee may even help prevent the development of Alzheimer’s disease, depression, some breast cancers and prostate cancers, endometrial cancer, and Parkinson’s disease.  And even though certain markers commonly associated with cardiovascular risk-factors are increased by coffee (blood pressure and homocysteine) at least in the short-term, moderate coffee consumption is associated with decreased risks of heart attacks and stroke for those regularly consuming it (as a stimulant it for those infrequently drinking coffee it may increase stroke risk right after consumption).

While it would be easier to remove all scientific details and nuance from health recommendations, coffee doesn’t quite allow for that yet.  What I hope this brief overview does is provide a starting point for you to become an informed advocate about your health with your trusted physician and other health care providers.  There is a great deal of research studying coffee and the hundreds of substances it contains.  While it is not easy to parse out all of the findings, for those at risk for diabetes and heart disease having a candid conversation about all of your lifestyle habits, including coffee is an important step.  Overall behavioral health has to include an ongoing assessment of your nutrition- and for many of us, coffee is one of the more frequent items on our nutrition log.


Information provided on this site is provided for the general public.  It is made available with the understanding that the author and publisher are not providing any medical, psychological, health, or other personal professional service.  Any information provided should not be considered complete and does not cover all diseases, disorders, syndromes, ailments, physical or mental conditions or their treatment.  This information should never be used in place of calling or visiting a medical health professional, mental health professional, or other appropriate competent health professional, who should be consulted prior to making any changes based on suggestions from this site or any inferences drawn from material presented on this site.  Any information about drugs that appears on this site is general in nature.  It does not include all possible uses, precautions, side effects, or interactions, nor is it intended as medical advice.  Anyone reading this information who is considering medication or drug changes should consult with his or her medical doctor.  J. Ryan Fuller, Ph.D. is a New York State licensed clinical psychologist.  He is not a medical doctor.  Anyone considering changes based on information provided on this site or inferred from that information should consult with his or her medical doctor.  The operator(s) of this site specifically disclaim all responsibility for any liability, loss or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the material on this site.


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REBT (Rational Emotive Behavior Therapy) Interview can be heard on the link above.

Rational Emotive Behavior Therapy (REBT) and Acceptance and Commitment Therapy (ACT) are compared in terms of how psychotherapy would be conducted.  Cognitive Behavior Therapy (CBT) and Behavior Therapy are similar, but are based on different theoretical models.  REBT is rooted in a cognitive (CBT) theoretical model, while ACT advocates emphasize models of learning without reliance on cognitive restructuring.

Acceptance and Commitment Therapy (ACT) and Rational Emotive Behavior Therapy (REBT) Transcript

Dr. Fuller: Ok, I am Ryan Fuller and I am very pleased to be with Dr. Windy Dryden, the author of well over a 180, soon 200, books on Rational-Emotive Behavior Therapy and many other topics on counseling and psychotherapy. He is currently a professor at Goldsmith College and has a successful private practice and I am pleased to have you in the office tonight.


Pregnant, Depressed, Anxious, and Antidepressant Medication

by New York Behavioral Health Staff

This question has become a real quandary for pregnant women. Thirty years ago, they were told by their doctors not to take any medication, prescription or OTC, that wasn’t absolutely necessary. And most moms-to-be adhered to that advice. But physicians’ advice, as well as the statistics on use of medications during pregnancy, seems to have changed drastically over the past 30 years.

Antidepressant Side Effects

In general, drug use is now significantly higher with all populations than it was decades ago. Some young women are even being prescribed antidepressants, for example, for menstrual problems or anti-anxiety drugs when they are worried about getting into the right college. So, if they become pregnant, they might have months of these meds in their bloodstream by the time they discover their condition.  Are we overdoing it? Should women of childbearing age be prescribed these medications when there are reports of birth defects being linked to mother’s use of prescriptions, such as SSRIs (anti-depressants), during pregnancy?

Medication During Pregnancy

The argument for this type of medication use during pregnancy is that the effects of untreated depression and/or anxiety on the woman can be harmful to the fetus. The same goes for medication for conditions such as asthma. So it is recommended that the expectant mother discuss the ramifications of each with her physician. But even more important, all reproductive-aged women need to be made aware of the potential benefits and risks (for a child in utero) of taking SSRIs.