ADHD, Meds, ACT, Therapy: An LCSW on Better Mental Health

Therapists and social workers are tasked with sitting and dealing with a lot of hard stuff for a living. I recently sat down with licensed clinical social worker (LCSW) Bryan Rieben – who’s been in private practice since the end of 2020. I asked when medication is “worth it,” how the systems we live in and politics we engage in impact our mental health, what actually helps people both inside and outside the therapist’s office, and what someone eyeing a career in mental health should know.

TLDR — What to know about therapy, medication, and mental health

  • LCSW Bryan Rieben treats identity work, grief, loss, depression, anxiety, trauma, and faith transitions.
  • Medication isn’t magic. It’s a tarp. It doesn’t necessarily stop the rain, but it can provide a covering so you can build in the storm.
  • Schools and workplaces are built for neurotypical attention. For many neurodivergent people, it’s the exact opposite. It can be a cage.
  • Therapy works most when the therapist-client relationship works — and hinges on the client’s ability to be transparent and honest in sessions.
  • Useful tools named in the conversation: CBT, EMDR, ART, and mindfulness/values-aligned work inspired by Eastern philosophies (ACT).
  • Progress shows up most when people do the work between sessions. Adopt a mindset of curiosity, instead of judgement, and ask yourself “Why?”
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Chapters

What people are bringing to the room

“I’ve been in private practice since the end of 2020,” LCSW Bryan Rieben says. His work runs through identity, grief and loss, depression and anxiety, and trauma work. Rieben says that a lot of the things he sees coming through his door are about many of the same things they have been for years – partners, family, processing childhood trauma, faith transitions.

However, he does note that he is seeing the impact of the job market in his office:

“I actually have quite a few clients that have been without work for a while or went a long time without finding a job despite their best efforts. So I know that that is a big deal. Lots of people are questioning their career choices and thinking about doing new things and exploring all the paths that exists for them.” — Bryan Rieben, LCSW

He also says the ugliness of our politics is bleeding into his work, as well:

“I do see a lot of folks that are perhaps being targeted by right-leaning politics. And so there is a lot of fear there that we also address. And like, how do you live in a world where your very existence is viewed as a sin.” — Bryan Rieben, LCSW

Meds: what they do, what they don’t, and when the tradeoff is worth it

It’s hard to talk about mental health without bringing up medication, the current political climate, anti-intellectual discourse. Rieben validated skepticism about Big Pharma, but highlighted the reality that for many, meds keep life livable.

He was candid and personal: “I myself am diagnosed ADHD and bipolar type two, and I am medicated for that, thankfully. Life without those medications is really, really challenging!”

He’s also not naive about the downsides: “There’s lots of side effects… Some of the more powerful ones result in side effects that perhaps never go away.” He acknowledges that people don’t want to be guinea pigs, lose themselves, or numb out. He understands that it can be a very laborious process, with a lot of trial and error, to find the right medication for someone — or finding a medication that has continued efficacy long-term.

Yet, at the same time, if a person is able to find the right medication and it improves their quality of life, “it may just be worth it.”

He shared a metaphor as an example of the role medications play in mental health:

“With a lot of my clients, I say: [Imagine] you’re trying to build a house. This house is your life that you want. It’s the relationships that you would like to see, the job that you like to have. You’re trying to build, but it is downpouring… You cannot get some of the materials that you need to make even just the foundation harden up. The medications don’t necessarily stop the rain, but they provide a covering [so] you can work on certain aspects and make the progress that you otherwise wouldn’t. If you can put up a substantial tarp, then you’re going to make a lot more progress. And that is [the role] medication often plays. You still have to build.” — Bryan Rieben, LCSW

While Rieben can’t prescribe medications as an LCSW, I still asked him about whether he thinks medications or skills and behavioral work should come first. His response was that it is different for everyone and can only really be determined on a case-by-case basis.

For conditions like his, which are caused by chemical imbalances, he likens it to a diabetic using insulin:

“It’s like someone with diabetes and they need insulin, right? Because their body just doesn’t work the way that other people’s bodies do that don’t need insulin. So in that case, medication is absolutely the go-to.” — Bryan Rieben, LCSW

However, even when the answer is strictly medication-based, he notes that people can often benefit greatly by pairing it with therapy — because their diagnoses often cause fallout with relationships, goals, or desires.

For those who don’t strictly need medication to improve their condition, Rieben takes more of a “wait-and-see” approach. He prefers to start by attempting to adapt thinking, reframe problems, and build new behaviors. If he doesn’t see success within 6-12 months, at that point he would start considering medication.

Though, he does note that there are always exceptions and what he ultimately does for each individual is highly dependent on their symptoms, potential risks to themselves and others, and additional factors.

Gene mapping and the price of access

While finding effective medications for people has historically involved trial and error, there’s new technology that could shorten that grind: Gene mapping.

While Rieben is not an expert on gene mapping himself, he lays out a general summary of the technology. Essentially, clinics can now use DNA analysis to see which biomarkers a client has and which medications would be most effective given their biomarkers.

This is providing a new era of hope for many — and Rieben is clearly excited about the potential. However, Rieben notes that he’s unsure how expensive gene mapping is or whether insurance policies cover it. And he acknowledges that there can often be a financial barrier to access medications, treatments, and therapy in general.

Schools, ADHD, and invisible barriers

As we discussed mental health, I couldn’t help but ask him how much some of these diagnoses, developmental issues, and mental health problems were just made up.

“I think it’s worth asking how many of these are socially imposed problems. Like ADHD: Is that really an issue or is it only an issue because our society demands that we are heads down focused 100 % of the time doing the job? While ADHD people are more… I don’t even want to use ‘distracted.’ They’re just aware of other things going on and it’s in their nature to check those out and address those things and then circle back to what they were doing.” — Casey Rock, Rock This World Host

While he believes there is nuance to this — and it really depends on what specifically is being talked about, he acknowledged that there are systemic issues that impact the individuals he sees:

“Schools are set up for a neurotypical person [who] has an easier time sitting and thinking about one topic at a time, that doesn’t have a desire to go and explore other things. And people with ADHD, for the most part, grasp concepts fairly quickly. It’s a superpower. If they’re sitting in the classroom, they might get it right away and be like, ‘Okay, I’m bored.’ They gravitate toward topics that are interesting to them.

If they can be allowed to go do that then, wow, [that would be] incredible. You look at like some of the top scientists, researchers, engineers, inventors, stuff like that. A lot of them had ADHD or some other kind of like mental health issue, right? The contributions that they’re able to produce to society as a whole is absolutely incredible.

But The school systems aren’t set up to allow a person that is neurodivergent to thrive. It’s the exact opposite. It’s a cage.” — Bryan Rieben, LCSW

Rieben makes it clear this isn’t the fault of teachers — noting that they often have to deal with more than 30 kids and could not possibly craft individualized educational strategies or give individual students undivided attention.

He also notes that, even on an individual level, things can be difficult for neurodivergent people — such as when hyperfocus meets partnership or family life: needs clash; timing clashes. That doesn’t mean someone with ADHD, for example, doesn’t care. Their brain is just locked onto a target and “they can’t really break away from that.”

The slow work of changing minds

The discussion of teachers’ plight with a sea of students and the impossibility of neurodivergent kids to get what they need in such a system raised larger questions about how we can begin to build a better society.

Rieben noted how rules often move faster than hearts. He brought up Ruby Bridges — the first black girl in an integrated school, and the obstacles that she faced on the daily — as a reminder that compliance isn’t conversion. “You can pass a law, but you can’t change a person’s mind about that. People’s minds just don’t change that simply.”

Rieben noted why change is, realistically, so difficult:

“[Imagine] I’m going to drop you into a foreign country and I’m going to ask you to solve a big problem over there. You just can’t. You have to know the history. You have to know like all the things. And that’s essentially what we do with people in the United States.

Even if you’re born here, you don’t know all the ins and outs. You don’t know all the history. You don’t know all the decisions that were made or why those decisions were made. We don’t know so much. And so correcting this is kind of overwhelming.” — Bryan Rieben, LCSW

Ultimately, we both see education, patience, and curiosity as a driver for change:

“I’m a big proponent of curiosity in general to solve all problems. I think if we could switch to a mindset where it’s more like curiosity to understanding instead of what we have now — [where you have] your expectations and biases and [make] decisions off of those. Trying to be curious about whatever and try and foster understanding: I think that would make a huge difference in just all of our lives and so many, so many things.” — Casey Rock, Rock This World Host

Rieben added an important and necessary caveat, though: “There needs to be a level of patience and grace. But, at the same time, I recognize my own privilege. I can afford patience. Other people can’t.”

What makes therapy work

When I asked Rieben what actually predicts change, the answer was pretty simple. “There’s a statistic out there,” Rieben says. “I don’t want to misrepresent the information, but I want to say it’s like 70% of progress that a person makes is due to the relationship with the therapist.” Simply having a therapist who is present and mindful can make all the difference in the world.

Modality still matters, of course, and he mentions a few he’s found effective:

  • CBT (Cognitive Behavioral Therapy) is kind of like the overarching canopy. Most everything else branches off from it, and it’s a well-established modality for change.
  • ACT (Acceptance and Commitment Therapy): A values-and-mindfulness-anchored approach that Rieben particularly loves. He says it’s “deeply rooted in kind of an Eastern philosophy” and that the goal is to connect to yourself through mindfulness and reflect on what it is that you value in order to align yourself more and more with that.
  • EMDR and ART (Eye Movement Desensitization and Reprocessing and Accelerated Resolution Therapy): For trauma, Rieben says ART and EMDR have been fantastic — especially for “single-incident” work. These both use bilateral eye movements that “help calm the brain.” In ART, specifically, you pair that with a new imagery, outcome, or belief system. Ultimately, you still remember the events of the trauma, but the traumatic feelings have been resolved and dissipated.

Additionally, one huge thing that Rieben says is a high indicator of success in a client is if they do the work outside therapy. He makes it clear that he doesn’t judge or blame anyone who can’t do the work outside therapy — as we all often have fires going on in our lives. But those who are able to do so generally see better results.

What to do between sessions (aka where most change sneaks in)

“Working on these things on their own” is where people turn the corner, Rieben says. The first weeks with a client can often feel like “putting out fires.” If he can get a person to a point where the fires are not raging, or they are able to work amidst them, the real work can begin.

When I asked him if he ever gives clients homework, he mentioned one thing only:

“The thing that someone can do, honestly, is self-reflection. You hear people say ‘Why do I keep doing that?’ Yeah! Can you ask that without the judgment or anger? If that’s all a person does, like they’re going to have some success. They’re going to have some changes because they’re looking at what’s going on for them internally or the external factors rather than just being like, ‘Hey, you need a change. You need to stop that.’

It’s like if there was a boat that was sinking, you’re just like ‘Why is this boat sinking?’ But you never went and looked for the leak or you never jumped in the water to patch it. It starts with that awareness.

Like really, ‘Why is it?’ ‘Why are there these problems?’ ‘Why am I struggling with this behavior or this thing in my life?’ And that leads to a greater understanding that is going to open up the mind.” — Bryan Rieben, LCSW

So if you find yourself critiquing and criticizing yourself this week, try to dig deeper. Don’t scold. Ask why — gently. Use what you find to facilitate changes and encourage growth.

Apps and therapist churn

When discussing therapy and mental health, it makes sense to talk about our increasingly digital world. I asked Rieben about apps like BetterHelp and Talkspace — and whether they help or exploitative to either therapists or clients.

For Rieben, he believes that “something’s better than nothing.” But he has a lot of reservations about where therapists focus might actually be and how consistently the users of these apps can see the same therapist. Given that the therapist-client relationship is one of the biggest contributors to effective change, he sees some potential problems with therapist churn and app users not always being able to get the same therapist.

The limitations of AI in therapy

We also discussed AI and the increasing role it is playing — not only as a therapist, but as a friend or even intimate partner.

Rieben admits that he tried using ChatGPT on a martial conflict — and that it actually had some great insights to share. However, he notes that this largely is because of the way that he framed the information that was fed to ChatGPT.

He notes that therapists are trained to be unbiased — and check their own biases at the door. And when you give ChatGPT good, solid, unbiased information, it is likely that you will get good, solid, results back.

However, even if you provide the best contextual engineering for a ChatGPT prompt, there are limits to what AI can actually do:

“Body language is so important to communication. AI cannot see that. If I am looking across from someone [as they speak], and I’m noticing a little bit of a tilt in their head or their leg is bouncing or something like that, I get a sense of what the emotion is here. And I’m going to ask about that rather than what they said. I know there are so many times when people [are] talking to me about a problem and that’s not actually the thing they need to talk about.” — Bryan Rieben, LCSW

In addition to body language, there are serious concerns about the ways that AI can overly validate people suffering from mental health issues and actually reinforce damaging behaviors or beliefs.

“I want to validate my clients. But if they’re wrong about something or they’re viewing something in a way that maybe isn’t accurate, I’m going to call them out on it in a kind way.” — Bryan Rieben, LCSW

What to know if you’re considering a career in mental health or social work

Interestingly, Rieben didn’t start his education or career with the plan of being a one-on-one therapist. His grad program emphasis was global social work. However, a family health crisis rerouted him.

He was offered a job at a community health center and went in honest — telling his supervisor that he had a lot to learn and needed to be molded into a therapist.

If you’re eyeing this field, that detail matters. People aren’t hiring your memorized techniques; they’re hiring your presence — and your willingness to be shaped. The skill that outlives every model is the same one he named early: “be present for a person.”

Rieben also notes that therapy is meant to be a safe space. While that doesn’t mean perfection, it does mean that therapists should be accountable to noticing their biases and setting them aside.

A few mental health tips you can actually use

  • Treat meds as a door, not a brick wall. If they quiet the storm, use that opening to build relationships, routines, and skills — not to avoid the work.
  • If school or career feels difficult, or makes you feel like a failure, reframe it. You weren’t broken. The system is. Bring that reframing into how you design your life and tackle issues.
  • Do one curious re-ask daily. “Why do I keep doing that?” Curiosity will beat self-contempt every time.
  • If you try an app, ask about continuity. How long can you keep your clinician? What happens if they leave? How often will you have to start over?
  • If you’re choosing a therapist, choose the relationship. The modality matters. The relationship moves mountains.

The strong case for therapy

I have used therapy myself. It has been literally life-changing for me. Even if you don’t necessarily have any pressing mental health emergencies or issues, still go see a therapist monthly because they are a good sounding board.

Therapists aren’t your friends or family. You can be more candid with a therapist than you can with people you know you and interact with daily. And it makes a difference even if you aren’t facing any sort of crisis. It’s a great relationship and resource to have.

And especially, if you are facing like a mental health crisis or difficulties in your life, get a therapist. Do whatever you can. There are places out there that have sliding scales and even pro bono options. So at least check in your communities and see what you can find.

And if you are in crisis right now, call 988 in the United States to reach the Crisis Hotline.

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Frequently asked questions about therapy, meds, and mental health

What kinds of things are therapists seeing right now?

Identity work, grief and loss, depression, anxiety, trauma, and faith transitions are all still prominent issues. However, job-market stress is an increasing variable in their work.

Are politics showing up in therapy?

Yes. Some clients feel targeted by divisive identity politics. Therapists are seeing the fear that creates and the toll of trying to live “in a world where your very existence is viewed as a sin.”

So… are medications “worth it”?

Sometimes, yes. LCSW Bryan Rieben validates Big Pharma skepticism and the real side effects. He also says for many people meds keep life livable. When the fit is right, “it may just be worth it.”

If meds help, do I still need therapy?

Often, yes. Especially when there is relational fallout or you need skills and support to actually use the breathing room meds create.

Which comes first: skills or meds?

Case-by-case. For conditions like ADHD and bipolar II, or where there is the potential for harm, meds can be foundational — “like insulin for diabetes.” For others, working on reframing and new behaviors, and evaluating in 6–12 months can make sense.

What about gene mapping — does it help pick meds?

Gene mapping is promising. Clinics use DNA biomarkers to narrow options so clients are less of a “guinea pig.” Cost and insurance coverage can be uneven though.

Are schools and workplaces built for everyone’s brain?

Not really. They’re built for neurotypical attention. For many neurodivergent folks, the setup can feel like a cage.

Is ADHD just “being distracted”?

No. It is simply a difference in attention and interest. Many ADHD folks grasp concepts quickly and lock onto what lights them up — a genuine superpower in the right environment.

Are teachers to blame for poor outcomes of neurodivergent kids?

No. Think 30+ kids and limited resources. The system isn’t built for individualized attention. Many teachers fight hard against this and do their best given the situation they are in.

What happens to relationships when hyperfocus meets real life?

Needs and timing can clash. It doesn’t mean neurodivergent people don’t care. It just means their brain is locked onto a target and “can’t really break away from that.”

Can laws fix stigma?

Laws can ban behaviors; they don’t flip beliefs. Case in point: Ruby Bridges and the first integrated school didn’t change minds overnight. It will take a lot more work to create lasting change.

What actually makes therapy work?

The therapist-client relationship. Something like 70% of progress comes from the therapist-client relationship. Feeling seen, heard, and cared for matters.

Do modalities still matter?

Yes. Useful tools therapists use include:

  • CBT (the big canopy many others branch from)
  • ACT (values + mindfulness; align life with what you actually value)
  • EMDR and ART for trauma (bilateral eye movements)

What’s one thing I can do between therapy sessions?

Adopt curiosity over judgment. Ask, “Why do I keep doing that?” — gently. Think leaky boat: Stop yelling at the boat and go find the leak.

Are therapy apps helpful or harmful?

“Something’s better than nothing,” but there are legitimate concerns about therapist churn and continuity. Since the therapist-client relationship drives change, repeatedly switching clinicians can undercut progress.

Can AI replace a therapist?

No. It can offer decent reflections if you feed it balanced context, but it can’t read body language or call you out when you need it. A human therapist will validate and (kindly) challenge.

I’m curious about becoming a therapist. Any real-world advice?

Presence beats perfection. Bryan was molded in community mental health with proactive supervision. Be honest about what you don’t know, get a great mentor, and learn to be deeply present.

What does “safe space” actually mean here?

Respectful, non-shaming, bias-checked as a practice. Not perfection — accountability.

How do I decide if medication is for me?

Work with your prescriber and therapist. If symptoms are rooted in brain chemistry (e.g., ADHD, bipolar II), meds may be the go-to. Otherwise, you can try skills-based approaches first and reassess within 6–12 months — sooner if safety is an issue.

How do I talk to myself differently this week?

Swap “Ugh, I did it again” for “What job is this behavior trying to do for me right now?” Curiosity opens doors that judgment slams.

If I try an app, what should I ask?

  • Can I keep the same clinician long-term?
  • What happens if they leave?
  • How often will I have to retell my story?

How do I pick a therapist?

Pick the relationship you can be honest in. Modality matters; the bond moves mountains.

I can’t afford therapy. Do I have options?

Check for sliding-scale clinics and pro bono pockets in your community. It’s not perfect access, but it’s worth looking.

Bottom line on meds?

They’re tools, not solutions. Use them to do the work on yourself you need to — don’t assume they have fixed the issue.

Bottom line on therapy?

Even if you aren’t experiencing a mental health crisis, therapy can help — because you can say things you can’t say to your friends or family, and be heard without their biases attached.