Leaders Series

Q&A with Richard Fischer, PhD, Psychoanalyst

We’re thankful to Dr. Fischer for his ongoing work in the mental health field and for sharing his thoughts with us.

Sunday, October 10, is World Mental Health Day. We interviewed Richard Fischer, PhD, a clinical psychologist who has been in private practice for 40 years, about the Covid-19 pandemic’s impact on mental health, coping with anxiety, and more.

Dr. Fischer has worked with some of the biggest names in modern mental health. He did an internship at UCSF Medical Center (Langley Porter Institute) and had the privilege of being supervised by Erik Erikson. He was a postdoctoral psychology fellow at Weill Cornell on a long-term unit treating hospitalized personality disorders following the approach of Dr. Otto Kernberg. He spent sixteen years working with James Masterson, and was a faculty member of the Masterson Institute, where he trained therapists nationally and internationally on the outpatient treatment of personality and mood disorders. Many of his patients also suffered from substance abuse. Dr. Fischer focuses on individual treatment as well as family and group modalities.

How has Covid affected the state of mental health in this country?
Covid came in as a trauma. We did not know what this was; we didn't even know how it was contagious. People were wiping down their groceries, people were dying in massive numbers, and it took away all our sense of control. We didn't know how to deal with it.

The major issue is social isolation. I have worked with people who have social phobias and social anxiety, and I worked very diligently to get them to be more comfortable socializing, and then we were told that socializing will kill you. So what did we do? Everyone went into a silo. We were told to socially isolate. Most of us get a sense of wellbeing by interacting socially, and we weren't allowed to do that. We're just beginning to get more comfortable with that, provided a new variant doesn't descend on us.

Was there a mental health crisis before Covid?
Yes, but people were socializing, they were drinking, they were shopping—they were quieting their anxiety in all sorts of ways, some of which were constructive and some of which were quite destructive. When they had that outlet, it wasn't as obvious. It's not accidental that when people were socially isolated, alcohol abuse went way up, spousal abuse went way up, depression and suicide went up. The ways we would comfort ourselves were no longer available.

Why are so many people experiencing anxiety?
It's about the loss of control. We all have an illusion that we can predict what things will happen in our lives, and we need that illusion to some degree. What's going on now has shattered that illusion, particularly Covid. The life we had has been taken away. Then in the background, there's the climate issue, kids going back to school, facing illness… We're living with a lack of predictability, which dramatically affects our sense of control. This has become a major issue.

Another issue that I think is a big part of anxiety is technology—the media, the internet, and social media, in particular. One thing we have to understand: The media is putting us in a fight or flight reaction. We were designed by evolution to have a fight or flight reaction on a short-term level. If a tiger walks into your office, you want to have a fight/flight reaction so you can get into a preparatory state. The problem with industrial living is when we're chronically in that fight/flight reaction, we have anxiety, we're predisposed to depression and all sorts of inflammatory reactions, because the stress hormones, namely cortisol and adrenaline, inflame our system. It’s not just our brains, but cardiovascular issues, diabetes, autoimmune disorders. We're not supposed to be in a chronic fight/flight reaction. 

How do clinicians figure out what’s causing someone’s anxiety?
It's always overstimulation of some sort. Early childhood trauma or even adult trauma—you have an earthquake and you lose everything—would be overstimulating. The first thing the clinician has to do is identify what precipitated it. Is it work stress? Is it relationship stress? Is it an illness? Is it financial stress? But very quickly, you have to move from the patient trying to control that stress, which they can’t, to identifying the internal stress reaction. Then, we have a whole host of ways of dealing with that, from exercise, to psychotherapy, to relaxation techniques, to systematic desensitization, to medication.

What are the best treatment approaches for anxiety?
Sometimes anxiety is a wildfire, and you have to quiet it down. The quickest way to do that is through medication, combined with anxiety-reducing techniques. Behavior therapists use systematic desensitization, relaxation techniques, meditation, and exercise. Getting people into an exercise program is extremely important. Anxiety sometimes interferes with sleep regulation, and since Covid, there's been a massive epidemic of sleep disorders not just among older people, but young people. I'm all for the symptomatic relief, because these are very anxious times, but there has to be an understanding of what is the breeding ground for anxiety.

Is there an acceptable level of anxiety?
Studies show that if a student is preparing for a test, we don't want them to have no anxiety, because a slight level of anxiety improves focus and attention. In fact, when you have kids with ADD, they give them stimulant medication that raises the adrenaline levels, which for me, would make me anxious. But for that kid, it just raises the level of adrenaline so they can focus. However, it's a bell-shaped curve, and very quickly, too much anxiety overwhelms the person, and they lose cognitive focus, they lose attention, and they lose a sense of wellbeing.

When should people seek help?
I think there are telltale signs. If the person has a panic attack, they have profuse sweating, they feel like they're choking, they have chest pain, and they go to the emergency room thinking they’re having a heart attack, but they do a test—no heart attack. If one is predisposed to panic attacks, they need to seek help. We're not all predisposed to feel anxious. If anxiety runs in the family, I'm going to look for that as a possible predisposition. Just like if I hear that 50% of the family were alcoholics. We have to assume that some people are genetically wired to feel more anxious.  

Much of your work focuses on personality disorders, mood disorders, and substance abuse. Why did you choose that focus?
I'm an old-timer, and when I was in training, we were taught to treat the person. Today, everything is symptom relief. About 30 years ago, managed care began to get a grip in healthcare. They said, “Give them some medication, give them some brief psychotherapy, and reduce their symptoms.” Where I came from, we treated the person, not just the symptoms. If you don't treat the person's personality, and they don't understand their personality, they’re going to be predisposed to developing all sorts of symptoms and it's going to be a revolving door. They're going to keep coming back. Personalities need to be managed in an ongoing way. The most important thing, starting in infancy, is a relationship and attachment between someone who needs care and someone who provides care. That’s part of the human condition.

People need a community that understands them. AA has been very useful for people with substance abuse. Group therapy is a very, very powerful tool for relationship problems, too. People will say, “I'm not a group person.” But eventually they would be, because having that interaction, not just with the therapists, but with a group of people who are all struggling, takes away a feeling of isolation, aloneness, and a sense of shame that you are the only one that feels this way,

Would that also help with anxiety?
Yes, because a lot of anxiety is relationship-based. When people have a deteriorating relationship, they feel very anxious and/or depressed. Learning how to manage yourself as you deal with another personality is extremely important.

You trained with one of the most influential analysts of the 20th century, Erik Erikson. What do you think he would say about mental health treatment today?
He would not be a happy man. Erikson spent his whole life's work studying the person. I think Erikson would just throw up his hands and say that it's not just treatment; society has become terribly dehumanized. He would see the whole society fragmenting, because it’s not about the person anymore. Erikson spoke about helping a person leave their job because it did not make them feel relevant and empowered as a person. Today, I work with people, and we just try to make them less anxious so they don't lose their job. It's a different world.

What should people look for when choosing a mental health provider?
You can’t argue with chemistry. Relationships produce powerful chemistry. When people come in and say, “You're the only one that I really feel comfortable with,” I don't think that should be ignored. On the other hand, some people will come in and say, “You're really good at what you do, but something just doesn't feel quite right in the way we relate.” I think that should be addressed too. I think people should seek out a couple of consultations—not a lot, where they get overwhelmed—but to get a feel for: Does that person not only know what they're doing, but do they get a sense of you? I think people should trust their judgment on that.

We’re thankful to Dr. Fischer for his ongoing work in the mental health field and for sharing his thoughts with us. If you or your loved ones need help accessing great mental health care, reach out to an expert health advisor for support throughout the process.

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