Welcome to the middle path

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Sporadic photos and notes from a Psyche-midwife, cheerleader, anthropologist--aka clinical social worker in therapy practice. Photos are usually mine except for those of historical events/famous people. Music relevant to the daily topic is often included in a web video embedded below the blog. Click on highlighted links in the copy to get to source or supplemental material. For contact information, see my website @ janasvoboda.com or click on the button to the right below. Join in the conversation.

Thursday, March 24, 2011

Follow Up: "My Therapist Doesn't Understand Me"

A few weeks ago a reader wrote about providers who "don't really get it."

In response to that post, he sent the following:

I think the reason it's a big deal for some of us is that we are so bombarded with "why can't you just..." "All you have to do is..." and other statements that suggest we should just "be normal," that it is a never-ending reminder that we aren't like "normal" people. And that is a big part of where the depression comes from. We can't "just..." get over it or let it go or whatever "normal" people are able to do. When someone understands that, and accepts us as is, that is the best form of therapy there is. It lets us feel like, even though we may not be "normal," we are legitimate and real and worthy.

Great comment.  Especially this line, which bears repeating: 
When someone understands (us) and accepts us as is, that is the best form of therapy there is.

Normal.  Now there's a concept that has caused more than its share of troubles.  Let's remember that any distribution of traits will spread, averages-wise, across a bell-shaped curve.  Even on the dropping off sides of that curve you are still talking within the range of "normal". And even on those edges, differences may not be significant in the long run.   The baby that walks at 9 months (my girls) and those who walk at 16 months (me and my son) are both on the outside of that "normal" middle lump of the curve (10-15 months).  Guess what?  We were all running at age 2.

We cause so much grief with our desire to categorize.  Judgment (as differed from discernment, which is more about wisdom than measurement) makes us feel better or worse than others.  Neither of these positions is good for us, decreasing either our compassion or our self-esteem. 

I am so glad to live in a generation where we have at least a few positive and culturally visually role models for gay and lesbian youth, persons with physical differences, stay-at-home dads and executive moms, and so on.  That wasn't true when I was growing up.   The information age can connect persons with the rarests of differences.

But we haven't come far enough.  Many of our culture's worst slurs and curses reflect our negativity towards differences in gender, mental and emotional functioning, and sexual orientation.  Although we are quick to display pink ribbons in support of sufferers of breast cancer, we remain in enormous denial to the choice aspects of mental dis-ease.  We blame the victims.  We stigmatize anxiety and depression as personal weaknesses, increasing isolation and shame for those suffering.

It's impossible to truly know another's experience.  I remember not getting why an obviously bright student of mine was such a crappy speller and made so many mistakes in his grammar.   I didn't get that dyslexia had little to do with other areas of intelligence and thought he was just being stubborn or lazy.  I was a great speller back then (don't call me out-- spell checker and years out of school have had their way with me) and figured everyone else could be the same.  We often think the world works the same for others as it does for us.  Think about color-blindness.  No matter how sure you are that there are clear differences in blue and green, someone else's eyes may see no difference there at all.  Which of you is "right"?  Whose experience is not reality?

In a previous post I talked about an author who described our experiences thus:  "It's as if we are all looking at the world through long, thin aluminum tubes, and thinking everyone else, with their own tubes, is seeing the same view".  We are born into these tubes.  If the only language we've heard is English, of course Chinese is going to sound strange and harsh to our ears the first time we hear it.  What we need to figure out is that our language sounds just as foreign to those not speaking it.  

We need to expand our vision.  The next few posts will talk more about being different in a culture that loves the norm. 

Here's a song to set the mood:

Wednesday, March 16, 2011

Fading Blues II: Understanding and Addressing Depression

  "I feel so ashamed."  "It's ridiculous I should be so unhappy.  Others have it so much worse." "I shouldn't be so weak".
     These are common comments in my office made by persons in the throes of depression.  Because it is a mood disorder, and because people assume moods  have causal links to what's happening in their lives, depression leaves people bewildered when they cannot link the feelings to situational events.  Even when they can, the other common depressive ruminations (guilt, hopelessness and helplessness) reinforce a very personal responsibility for the symptoms.
 "I feel like a burden."
"I should be able to handle this."
"I'm broken."

These thoughts are symptoms that arise from the disorder.

When one has a fever, one doesn't usually think "I shouldn't be so hot."  A person with Type 1 diabetes doesn't tell themselves or their doctor "I really should have my pancreas under better control."  But when our brains are screwing up, we take it really personally.  We confuse our mind/soul/personality with our brain.  And we think we are supposed to be in charge of it.

The brain is an organ; a very complicated one. It interlinks with a intricate endocrine system over which we have little conscious control.  That system tells our body such things as "wake up", "be energetic", "get drowsy".   In his Feb 2011 New Scientist article "Days of Wonder", Roger Highfield charts the mysteries of the complicated chemical factory that is our human body as it goes about an average day.  From the moment we wake up, when perifornical orexin neurons start our day by alerting the sympathetic nervous system to get going, to the time we ready for sleep and the dark triggers a chemical dose of drowsiness to quiet the system, hundreds of complex biological processes are happening.  Like Japan's nuclear power plants, there are dozens of redundant mechanisms to prevent the inevitable mishaps from collapsing us.  And like Fukushima, sometimes there are enough failures of those mechanisms that there are catastrophic results.

In depression, there is many potential failures (or more benignly, design issues) that can happen.  As psychiatrist Jim Phelps explains (buy his book already!), "A big part of depression is a single gene."
A person no more chooses to carry this particular gene than the one for say, hairy knuckles or that one that makes your pee smell funny after you eat asparagus.

Other things that can increase likelihood a person has a depressive episode are as varied as season and latitude, daylight savings time (!), hormonal changes (pregnancy and postpartum, menstrual cycles,  and menopause for women), and medication (including some you'd never think of-- even certain antibiotics, such as Cipro).  The linked list doesn't include antihistamines, which seem to cause depressive symptoms for me.  Every body is different.  If you notice you have a consistent negative response to a medication, consider reporting that to the FDA here.   These anecdotal reports add up and make a difference if there are enough of them.  I remember back in the day it was commonly thought that there was no such thing as a withdrawal syndrome for folks on antidepressants.  It wasn't until enough people complained to FDA and doctors that they were having serious issues that guidelines for slow tapering of SSRIs became common.

A more obvious causal relationship can be made for depression in a person who has been through one or a series of traumatic or stressful events.  Even then, it is likely the physical response of the body's bombardment with stress chemicals that explains the lethargy, mental fogginess and emotional reactivity of severe depression, not just the psychological effects.

How can you mediate the body's reaction to these difficulties?  There are a few straight-forward paths to wellness, whether your symptoms are aches of the physical or psyche:
  1. Practice good sleep/wake habits  to support the endocrine system's ability to do its complex job.  
  2. Minimize late night light and get a reasonable amount of daily fresh air and sunshine.
  3. Eat well:  adequate nutrition is essential for good mental health.
  4. Exercise is neurogenerative. There are dozens of studies showing its benefit to mental well-being.
  5. Social connection is very predictive of happiness.   Depression encourages withdrawal.  While reflection is good to a point, don't isolate.  Find ways to increase community.  If you are too shy or depressed to go out, at least go online, and find a support group/chat where you can connect with others.
  6.  Count your blessings.  Pay attention to what is going well in your life and keeping a journal of gratitudes.
  7. Address the unproductive inner focus by finding ways of being in service. 
  8. Find and practice ways of giving your life meaning.
  9. Develop a spiritual discipline that supports compassion to self and others.
  10. Learn to recognize depressive cognition (thoughts) as symptoms rather than reality.
  11. Minimize your exposure to avoidable stresses as you would to secondary smoke. 
  12. When stress is unavoidable, learn ways to decrease its impact through Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, meditation, prayer, focused distraction, creativity or other means.
As always, click on highlighted links for more information.

    Sunday, March 13, 2011

    It's a Small World After All: Our Brothers and Sisters in Japan

    Friday a week ago I listened in sad silence to storyteller Alton Takiyama-Chung tell of Japanese Americans interred by our government during the war.  A week later I was surfing the internet following a lecture at university, checking up some references given by the speaker.  During the lecture I had noticed the screen shaking a few times, and wondered if the time if we'd had a small tremblor.  I remembered this as I was online and hit my bookmark for the USGS earthquake map.  It showed a massive 8.9 quake had just hit Japan.

    At first I thought the site had been hacked.  Earthquake magnitudes are measured on the Richter scale, in which every 1 point value represents an increase of 10 times the amount of energy.  Michigan Tech's site for young seismographers gives this simple explanation:  "Think of it in terms of the energy released by explosives: a magnitude 1 seismic wave releases as much energy as blowing up 6 ounces of TNT. A magnitude 8 earthquake releases as much energy as detonating 6 million tons of TNT."  I'm thinking it must be hoaxAn 8.9 earthquake would be 700 times more powerful than the one that hit Haiti.

    I switched to BBC, and watched in horror as the events of the earthquake and ensuing tsunami unfolded.  Unlike technologically poor Haiti, coverage of the destruction was immediate.  Hundreds of videos of the quake and the wave were posted, some as they were happening.  I couldn't turn away.  For hours.

     I wrote an immediate email to the two Japanese highschoolers we had hosted from Tokyo a couple of years before.  I was relieved to get a response from Yasu a few hours later:

    Good evening.
    I’m sorry for delaying in my mail.

    Damage in my country is more awful.
    However, I do not have the problem.
    Please relieve.

    I was in the school during the earthquake.
    So, I came home walking from there for three time.
    But, the house is far and there is a friend who stayed at the school,too.

    Thank you for worrying.
    I want to meet again.

    The next day, all the way here in America, one of Oregon's own was washed out to sea photographing the wave's arrival from Japan.

    For Whom the Bell Tolls 

    No man is an island,
    Entire of itself.
    Each is a piece of the continent,
    A part of the main.
    If a clod be washed away by the sea,
    Europe is the less.
    As well as if a promontory were.
    As well as if a manner of thine own
    Or of thine friend's were.
    Each man's death diminishes me,
    For I am involved in mankind.
    Therefore, send not to know
    For whom the bell tolls,
    It tolls for thee.
    --John Donne
    We are all connected.  No matter how different we seem or pretend to be, we connect in our ability to suffer and to care.  We are here to be here, to love and ease the paths of others and give meaning to our birth and life.  

    It is heartening to see the governments of China and Russia-- no friends, historically, to Japan-- sending relief and rescue crews to the stricken country.  Our own country, less than three generations ago locking up its citizens of Japanese heritage, is providing assistance and support in many ways.  We all live on one planet.  We are more alike than different. 

    You can help.  Donate to relief agencies such as AmeriCorps or Doctors Without Borders. Check out CharityNavigator.Org to find reputable sites.  Make your dollar count:  those cell phone donations cost more and take up to three months to process, since the agencies have to wait on the money from your paid bill.  Pay by check or directly by credit card to the agency.  Even a few dollars can make a difference.

    Here's a video of Alton Chung performing a few minutes of his poignant story of a Japanese American soldier during WWII.


    Thursday, March 10, 2011

    From the Advice Column: My Therapist Doesn't Understand

    I received a note from a reader this week:
    "As someone who suffers from anxiety/panic and the resultant depression that goes along with those, I find it very frustrating that therapists, and even psychiatrists, really don't understand what this is like. I mean, yeah, they understand it academically, but not from having the actual experience. What do you think about this?"

    What I think is that it can be very frustrating to feel your experience of reality is being questioned by someone else who doesn't get it.  But I'd add that if I had been through everything all my clients have been through-- cancer, horrific abuse, war trauma, loss of a limb or ability to walk or everything I owned in a house fire for just a few-- I don't know that I would be able to practice.  On the other hand, I've been through some things.  And I think most people with some compassion and insight know what it feels like to be scared, hopeless, furious, or any of those other intense emotions.  They might not know exactly what it feels like to have a panic attack, just like your physician may not know what it feels like to have a heart attack.  But they've seen plenty.  They should still be able to treat you effectively.  I don't mean that to sound snarky.  I think it helps a lot to talk to someone who has been through your particular experience, just to know more certainly that you're not alone in what you are experiencing.  That's why I often refer clients to peer support groups or give them articles from people who've been there.

    The best practitioners I know fall somewhere in the range of "the wounded healer", as Jung calls it.  They've been through enough hardship to understand that life isn't all roses.  They've seen and felt suffering on a level to take it seriously. They can relate, if not to your specific dilemma, to the suffering it causes. Suffering is inevitable if you live long enough. I don't think they need to have directly experienced a particular symptom to understand the effects it can have on you or how to help you address it.

    That aside, I remember with big chagrin being a young, childless family therapist and telling people with authority how to handle their kids or marriages.  I remember at 25 becoming frustrated with a patient addicted to anxiolytics (medication for relief of anxiety) and telling him he really didn't have a thing to be anxious about, beings as he was not doing diddly squat with his life.  For me, getting some more life experience was humbling and helpful.  The older I get, the less black and white my thinking becomes-- and thank goodness.  I still think I was helpful, most of the time.  I also think at times I was a more than a little clueless.   I appreciate the clients who called me out, saying, "I don't think you are really getting this."  I appreciate the varieties of human experience, and the gift my practice gives me of having more of them vicariously than any one life could hold.  Each year I feel my heart expanding in compassion, and "that little aluminum tube through which we all look at the world, thinking all others are seeing the same scene through their tube", enlarging.

    Bottom line:  if you don't think your therapist gets you, tell them.  Be ready to own your own shist, so to speak.  We are, in other wise words of Jung, "dirty little projectors", often unconsciously foisting our own shame and defensiveness onto the other.  Look clearly at that first.  Be curious and open to information as well as clear as you can be of your experience and your interpretations of it.  Be willing to let go of your assumptions if they really aren't in line with your caregiver's intention.  Give it a little time to see if maybe you are just dealing with vestiges of resistance.  Even bad habits are afraid of dying. 

    If after honest conversation, reflection, deep listening for understanding and curious compassion you feel unheard, disrespected or just plain mis-matched, remember this is your nickel.  You can vote with your feet.  You can and should discuss your reasoning and even ask for a referral to someone that could be a better fit.

    Nobody can be everybody's everything (and if say they are, run).  I don't make it with all my clients.  Earlier in my career I saw this as a big failure.  But then I read a passage in a book on the Zen of Falling in Love that shifted things for me.  It was something along the line of, "you may have chosen a perfectly outstanding apple, with stellar apple qualities.  But if you want a pear, you're not going get what you what."  Now you have to choose-- learn to deal with pear-ness, or go out and find an apple.  There are deficits, benefits and chances for growth both ways.

    But if you feel humiliated, harassed, dismissed-- and you've discussed this to no positive outcome-- ask for a referral or ask others you trust.  Finding a good therapist isn't much different from finding a perfect pair of jeans or shoes. You might have to shop around and try a few before you find what really works for you.

    Like most therapists, I have been in therapy.  Sometimes for a few short sessions for a tune-up or problem solving, and sometimes for longer when I needed to dig to get at some perspective or to process something heavy.  I have met with perfectly delightful clinicians who frankly were not what I needed at the time.  Sometimes I needed a handholder and got an asskicker; sometimes the opposite.  I like very active therapy, and the smile-nod-how-does-that-make-you-feel sessions make me feel crazy.  Maybe that would have been a good thing if I'd stuck around longer to find out, but at my age I have some clear ideas of what helps and what doesn't, and I can get close to that level of feedback from my cat.  We all have our preferences.

    On the other side of the couch, I may move way too fast and feel aggressive to a client who wants much slower, gentler and contemplative experience.  It's not a bad way to work; but it isn't the way I work.  In such circumstance, I may suggest they'd  find the therapy experience more comfortable and valuable with someone who practices in a different way.  When I refer out like that, it isn't a rejection of the client.  I am truly hoping to find a better match so progress can be made.  I have to get my ego out the door and do what's best for a unique individual.

    The take home, as they say, is "know thyself."  This includes knowing your strengths and preferences and warts and defensiveness.  Bring your whole self into the office.  Ask for what you need .  You still may not get it, but it sure as heck improves the chances.  And speaking only for myself, I love it when clients throw me a little education about their diagnosis, recent research on it, and area resources.  I do my best to keep up, but as a generalist, there's no way I'm going to know everything.

    Thanks for the thought-provoking comment.  Hope to see more of these inquires as we continue muddling through the middle path. 

    Related readings:
    How to Do Therapy Part One:  Finding a Therapist
    How to Do Therapy Part Two: Bang for the Buck

    Thursday, March 3, 2011

    Fading the Blue Gene: Cognitive Behavioral Approaches to Treating Depression

    Remember losing a tooth when you were a kid?  How you could hardly leave that hole it left alone?  How big it felt, how you couldn't stop fiddling with it and poking the space where the tooth used to be with your tongue or finger?  Maybe for a while it drove you crazy.  Maybe for a while it was all you could think about. 

    And then after a while, you forgot about it.

    OK, depression is not much like losing a tooth.  The link here is the idea that when you pay a lot of attention to something, it occupies a lot of space in your mind.  

    You know those cartoons where someone stubs his toe so he bites his thumb?  It doesn't make much sense that adding pain could subtract from it.  But what's effective isn't the addition of a new pain, it's the distraction from the original one.  When we use a focused distraction, it's not that the pain isn't real.  It's that we are choosing to focus our minds and energies elsewhere.  This is part of the thinking behind all that complicated breathing they teach in Lamaze to control pain during childbirth.  There's some neuroscience and other physiology there too, but the simple part is:  it's hard to pay as much attention to pain when you are trying to remember all those patterns to the choo-choo breathes.

    In the quirky and beautiful French film MicMacs, protagonist Bazil deals with his depression and PTSD by reciting obscure history facts to himself when triggered.  He's practicing a form of Cognitive Behavioral Therapy.  As the name implies, CBT aims to change thinking and actions from nonproductive or destructive patterns to those that support health.

    When we are depressed, we ruminate-- obsessively mull over negative thoughts.  The original thoughts are spontaneous; we can't control them.  But by repeating them over and over in our mind we create neural bridges that strengthen them.  What we hear over and over (even from our own in-the-moment-distorted minds) seems believable.  At minimum, we wear a groove that we can now slide more easily down.  If you've ever studied music, think of it like chords or scales.  No one is born knowing how to play a C chord.   You learn it, and at first you have to think about it.  On the piano, C E G: white keys, each with a black between them.  If you've practiced them often enough, you can form the chord with your fingers even if the instrument is nowhere in sight.  If you now pretend to play a D chord, you know that middle finger moves up, to hit the black note in the middle of the chord.  You don't really even have to think about it.  After a while it becomes automatic.

    Thoughts can be like this too.  We have a spontaneous thought, such as "Life sucks."  Let's say we don't know exactly why we are thinking it.  If we start ruminating about it, being the problem-solving and pattern seeking people we are, we can probably come up with some evidence to support the thought.  Because we are sorting for supportive evidence, we disregard or fail to look for exceptions to the thought.  After a while, the evidence we've selected comes easier to the fore.  After a longer while, it comes automatically.  And because it is so present, so pervasive...

    We believe it.

    One way to deal with depression is to question the thoughts and the narrative we use to support them.  As mentioned in a previous blog on Obsessive Compulsive Disorder, everyone has crazy thoughts.  The difference in folks with OCD is they pay attention to them.  Say you are driving down the street and you think, out of nowhere, "I could serve my car into that oncoming semi."  Who knows where that thought came from?  Maybe you saw a movie where it happened, or heard a news story, or maybe you just had a random "brain fart."  Most people who have that thought might be momentarily disturbed.  They think, "Where did that come from?"  But the next minute they resume thinking about the burrito they are off to get, or singing along to the radio.  People with OCD have a different reaction.  They think, "How could I think that?  What sort of monster am I?  Does that mean I want to do that?  What if I DID do that?  What if I can't control wanting to do that?"  They go over and over the scenario.  Maybe eventually they can't even drive, because they are afraid of having the thoughts or of acting on them.

    In depression, minds can get sticky in a similar way.  Our task is not to control the original thought, but our responses to them.  We can do this in many ways.  Focused distraction--  intentionally turning the mind to something else-- is one.  Singing, paying attention to sensory detail, doing math-- it hardly matters what it is as long as it's a less harming thought.  See Managing the Monkey Mind for more on this. 

    As AA says, it's simple, but not easy.  Just like scales, learning a new skill takes time and lots and lots of practice.  If you have depression, you've had lots of practice in negative thinking and narratives that support why you feel so crappy.  And as noted in the last post, it's not that you aren't really feeling that crappy.  The point is the way you are addressing it can change, and that change can do you good.

    CBT has been found to be as effective as antidepressants in alleviating depression.  Other CBT interventions and more on how it works coming up-- stay tuned!
     Meanwhile, here's a positive thinking song from Gloria Gaynor:  dance it out.

    Tuesday, March 1, 2011

    More Bytes on the Black Dog

    If you are one of the rare few that hasn't had at least a two-week case of the blues, it can be hard to fathom what it's like to be in the maw of what Churchill called his "Black Dog"-- a companion both familiar and dangerous.

    Depression comes in all shapes and sizes.  There's dysthymia, a sort of a profound negativity and sour or melancholy disposition that's hung on for two years or more.  There's major depression, which can oddly enough be mild to severe, and in the latter form be accompanied by psychosis.  In kids, the chief symptom of depression can be irritability.  There's cyclothymia/bipolar two ("soft" bipolar) in which low moods alternate with normal or expanded ones.  Then there's Bipolar One-- what used to be called Manic-Depression, in which the highs can be WAY more damaging, accompanied as they often are with delusions of grandeur, paranoia, and really out of character behavior.  Read the last few days' infotainment news to see examples of a current celebrity demonstrating many of those symptoms.  (Note:  you can't diagnose based on news reports.  Said celeb may also be showing symptoms of heavy amphetamine use or even a brain/thyroid tumor.  But's he's doing a bang up job of illustrating the non-stop energy and grandiosity of someone in the throes of a manic illness).

    The chief features of garden variety depression are the low moods, cognitive cloudiness, ruminations and withdrawal from activity.   Depression is a biological illness, not just a "thinking" problem.  (Don't forget-- your brain is IN your body).  Stomach issues are very common-- did you know your stomach is a second brain?  Other aches and pains increase as well.  Some of this may be strictly physiological, but some of it is an offshoot of the cognitive changes that occur when we are depressed, specifically ruminating thoughts.

    Rumination means focusing too much on distress, its causes and its consequences.  Marni Jackson's book, "Pain: The Fifth Vital Sign," gives a vivid example.  The author is happily biking down a country path, enjoying the sun, the company, the ride, when she feels something hit her mouth.  Suddenly her world temporarily collapses into a very small place: she's been stung by a bee, and she's no longer thinking about the beautiful day, her family, the bike ride.  She's in pain, and that's all there is in the world for a time.

    Depression is often like that.  A pain so intense, so overwhelming that it knocks the importance of everything else out.  Alternately, it can be a numbness that completely blocks the possibility of feeling joy.  In either case, the depressed mind mulls over and over the pain or numbness, searching for reasons and filling in the narrative with explanations of deservedness, hopelessness. helplessness-- the cognitive triad mentioned in the last post.

    While loss and tragic circumstance can lead to depression, they aren't necessary as explanations.  Brilliant, beautiful, gifted and successful people suffer along with and sometimes as much as those who've been beset by real-life horrors.  Sometimes that can make it even harder.  "Why are you so miserable?  You have a wonderful (fill in the blank: spouse/career/job/family/life)".  Such statements are no more helpful than telling an amputee that s/he shouldn't have pain in an absent limb.  It doesn't matter whether it looks like there's a reason-- the pain is very real.  Blaming one for feeling it only makes it worse, adding guilt to the burden.

    But like the amputee, the migraine sufferer or the victim of losses, intense focus on the pain does nothing helpful either.   One must find that strange balance between denial and indulgence-- acknowledging the pain, addressing it where possible, and bringing focused attention to something besides its insidious, hypnotic insistance that it is all that exists or matters.  Remembering that acceptance is not the same as approval, we can work on being a compassionate witness to our emotional state instead of consumed by it,

    Next blog:  cognitive approaches to managing depression.