Anxiety and Evolution

Crap, I am anxious all the time, and so are most people I know. 

What gives? 

The conventional reason is that there are evolutionary advantages to being anxious. Essentially, the argument runs that our ancestors who were worried were more likely to gather nuts for the winter, watch out for predators, and avoid the annual Caveman Cliff Jumping Competition and were therefore more likely to survive. For modern people who don't live in poverty or a war-torn country, anxiety is a remnant of an earlier time. Here is a synopsis of this idea. 

I don't believe this theory. I don't think there is an evolutionary advantage to being anxious. Ok, maybe a little bit of anxiety helps motivate you to do the stuff you need to do - study for a test instead of partying for instance. But how well do you perform with a knot in your gut and worries in your head? 

Evolution has two main goals - survival and reproduction - and I contend anxiety doesn't help with either. Would you rather go hunting when you felt calm or anxious? How about picking up a potential sex partner? Anxiety is catchy and it is a libido killer.

I would say that being alert has an evolutionary advantage. Being alert to danger can keep you alive. An alert hunter is aware but calm, receptive to sight, sound, and smell, patient and poised to strike. An anxious hunter is more prone to drop his spear.

So why are so many people in our society anxious? I believe that anxiety is not left-over from an earlier age, but rather created by the isolation of this age. In this society, most of us lack a connection to an extended family group or meaningful community, we don't live close to nature, we don't have a sense of our place in the cosmos, and we don't know what the hell we are doing here. We feel alone and without a sense of purpose. And on a day in day out basis, that is more anxiety making than having to watch out for saber tooth tigers and woolly mammoths.

Chemical Imbalance

Once in a while, I hear a bit of news that gives me hope. Today, the Department of Health and Human Services said that the CEO of Forest Laboratories, Howard Solomon could no longer do business with the government as punishment for his company's marketing of its antidepressants Celexa and Lexapro to children prior to FDA approval. Here is the full story. 

This means Forest Labs has to dump Solomon because, like every drug company, it needs the US govt as a buyer. In the bigger picture it means the government may start going after CEOs from all sorts of different industries when their companies do illegal things. About time...

It is worth noting that the govt also slapped Forest Labs with a $313 million fine, and that this kind of money is chump change to the company. Money is of course power, and the drug companies have way too much power in the way mental health care is carried out in this country. They pull the strings of the lawmakers, they fund and therefore influence the research, they send out teams of attractive salespeople who use perks to influence doctors, and they put commercials on tv telling you to "talk to your doctor" about their latest drug to make your life better. Here is Chris Rock talking about these commercials:

For the record, I am not against psych meds. I have worked with people whose lives have been saved by these drugs. I often suggest that clients see psychiatrists for med evals.

I think my problem with psych meds can be summed up by the words "chemical imbalance".  I don't know where the term came from, but it is genius. My life is not working because I have a chemical imbalance. Solution: a pill to balance my chemicals. It's so elegant. 

This formulation divorces your life problem from your life. Its just the chemicals in your head. When people start thinking this way, they stop thinking about their family, their work, their attitude, their exercise, their relationship with drugs and alcohol, thier hopes, their dreams, their demons. They become dis-empowered. 

Again, I am for the idea of pills being part of the solution in some cases. I am against the idea of pills being the solution.

Ultimately, I believe life is for growing, and I believe that the drug companies and their hordes of cash do a disservice to humanity by selling us on the idea that problems in living can be solved simply by taking a pill.

7CBTY6ZNNRR3

You are (probably) not bipolar!

The word "bipolar" has now entered the vocabulary of the average 17 year old American. On the street, the word is used to describe someone who has intense, unpredictable mood swings, as in "Ever since my boyfriend broke up with me, I have been so bipolar. I am fine one moment and then I just feel like crying." 

When a word becomes slang its original meaning gets watered down (see, "awesome," "pimp," and "rock star"). This is well and good. The problem here is that the loose definition of this word on the street mirrors the loose definition of the word in the psychiatric world. And that is a problem.

Here is the full DSM-IV criteria for bipolar disorder. For the record, in this post, I am talking about bipolar 1 disorder which involves full-blown manic episodes, not bipolar II disorder which involves hypo-manic (meaning smaller manic), episodes.

As the name implies, bi-polar disorder, which used to be called manic-depression, involves two poles - mania and depression. Technically, you don't actually have to have depression to be bi-polar but most people with bi-polar have both. 

Most people know more or less what depression looks like, but most people have not seen full-on mania. Therefore I will try to describe it:

A manic episode is essentially a huge increase of energy in the person's system. It is not subtle. It differs from a normal mood swing because a. it is much more intense and b. It lasts at least a week and without meds can go on for weeks before it peters out.

Because of all this energy the person experiencing the episode may:

1. 1. need much less sleep than normal. (While this is not a requirement for a manic episode, I have not seen a case where this was not true.) This is different from insomnia. With insomnia a person wants to sleep, and feels crappy because they cannot. With a manic episode, the person doesn't need to sleep as much as normal and still has plenty of energy.
2. talk a mile a minute, as if their words cannot catch up to the speed of their thoughts and this is exactly what is happening. Sometimes their speech is not pressured but their thoughts are still moving too fast for the person to follow them.
3.  be super distracted, again due to the speed of their thoughts. 
4. experience a massive increase in their sense of self-importance. At one end of the spectrum this looks as if the person suddenly becomes as confident as the Situation on Jersey Shore and at the other end, the person truly believes they are like Jesus or Neo, blessed with special powers and here to save other people.
5. loose inhibition and do things they normally wouldn't such as go on gambling, sex, or shopping sprees.
6. work single-mindedly and with great intensity on a project. Sometimes the person can make progress (it is likely that some great works of art have been created during manic episodes). Other times, the person is just too disorganized to make anything other than a mess.
7. feel either GREAT or very irritable
8. become psychotic (losing touch with reality) and think all number of crazy things such as they are the savior, people are out to get them, they have special powers, ect.

Some of these symptoms can be caused by problems other than bi-polar disorder. For a psychiatrist or a therapist, it can be hard when taking someone's history to sus out whether the person truly has bi-polar disorder. What sounds like bi-polar disorder can actually be a history of drug abuse, particularly cocaine or meth abuse. The drama that surrounds the life of someone with borderline personality disorder can also look like bi-polar disorder.

Another way people get misdiagnosed with bipolar disorder is that they are helped by mood stabilizers, the class of medication used to treat bi-polar disorder, even though they are not bi-polar. Here is what I have seen happen: A client gives a murky history to their overworked psychiatrist and in the history it sounds like their could be symptoms of bi-polar disorder. The psychiatrist wants to treat with a mood stabilizer and so diagnoses the patient with bi-polar disorder.

Diagnoses in general, including misdiagnoses, tend to follow the client. Other clinicians will see the diagnosis and unless they are really on the ball, they will just keep the diagnosis already in place. 

The primary treatment for bipolar disorder is medicine. The person will be told to take their meds or risk having another episode. They will be told to watch for red flags that they are getting manic, and if they notice red flags, to call their psychiatrist to up their meds. This is not a bad thing, and mood stabilizers have helped a number of people with bipolar disorder to lead normal lives.

The problem is, if you are misdiagnosed as bipolar, you will be told you have a biological illness for life and the treatment is to take your meds. These meds may help but they may also zonk you out, so you don't feel fully awake. Some cause pretty severe weight gain. Psychosocial treatments (therapy, group therapy) that focus on your life circumstances will likely be de-emphasized in your treatment plan. This takes away your autonomy - the sense that with help you can grow and change your life for the better. Instead, you have an illness and you need meds.

This is natural in a health care system that wants to minimize costs - drugs are cheaper than therapy.

My advice: if you receive a diagnosis of bipolar disorder, do your research and really talk it over with the person who diagnosed you. Do not be a passive recipient of psychiatric care. Mood stabilizers have saved the lives of some people with bipolar disorder and others that do not have bipolar, but no matter what diagnosis you actually have, do not underestimate the role of your relationships, work, health habits, thoughts, feelings, and your own will in creating a life that works.

Wishing things were different

This is my definition of mental health: the ability to see and accept reality and react to it constructively. 

In an earlier post, I wrote about a client letting herself have her feelings instead of telling herself how she should feel. The reason I try not to tell myself I should feel a certain way is that it doesn't work. If I feel sad, and then I tell myself I shouldn't feel sad, I end up feeling sad and guilty for feeling sad. The reason it doesn't work is that it puts my wish to feel not sad against the reality that I feel sad. And in the fight between what I want and reality, reality always wins.  

Getting rid of shoulds about me is half the battle. The other half is getting rid of shoulds about the world. Here is one of my favorite Buddhist teachers, Pema Chodron talking about this concept:

I worked with a woman who had spent the last decade of her life wanting the father of her son (who she was no longer with) to be a better father. He was in and out of the boy's life and frequently broke dates to spend time with his son. Every time he stood up her son, this woman was shocked, angry, and hurt. This went on for literally the boy's whole life. "He should be a better father," she said, her body tight with her desire for it to be so. 

"You are right," I said "he should, but he isn't." 

I wanted her to accept the reality of who this man was because then she could choose how best to protect her son and herself from the disappointment of his failure to show up.  That's the thing.  Acceptance brings choice. He's a lousy father. Now what do I do.

Instead, her should kept her banging her head against the same wall of how he actually was: He should be this way. Bonk! He's not. Repeat.

Worse, because she could not accept that this man had failed in his responsibility to be a father, she somehow made it her fault. She beat herself up when he broke appointments, told herself that if she had been a better woman to him when they were together, things would be different. 

As crazy and destructive as this was, there was a certain logic to it: things were not as she wanted them to be, so someone had to be to blame. She wasn't ready to blame him, so she blamed herself.

It was easier for her to attack herself than it was to accept the reality of who this guy was. As I write this, I realize I don't know why this was so hard for her. Of course, accepting that your son is not going to have the father you want him to have is crushing, but I suspect there was a shadow from her past making it even harder to face this reality.

It was short-term work, and we did not have the time to go deeper. Try as I might, I don't think I ever got her to loosen the grip of her passionate desire for him to be different. On one level, she knew he wasn't going to be the father she wanted him to be, but on another level, she kept hoping, hoping. Letting go is not easy. 

Self-blessing

Photo from Tom Curtis

http://www.freedigitalphotos.net/images/view_photog.php?photogid=178

 

In the blurb I wrote about myself for my provider profile on the insurance website, I talk about helping clients be kinder with themselves. Yet when I actually try to help clients with this, I often get the question: “How do I do this?” I’m still working this out myself.

This poem by Galway Kinnell has helped me:

St. Francis And The Sow:

The bud

stands for all things,

even those things that don't flower,

for everything flowers, from within, of self-blessing;

though sometimes it is necessary

to reteach a thing its loveliness,

to put a hand on its brow

of the flower

and retell it in words and in touch

it is lovely

until it flowers again from within, of self-blessing;

as St. Francis

put his hand on the creased forehead

of the sow, and told her in words and in touch

blessings of earth on the sow, and the sow

began remembering all down her thick length,

from the earthen snout all the way

through the fodder and slops to the spiritual curl of

the tail,

from the hard spininess spiked out from the spine

down through the great broken heart

to the blue milken dreaminess spurting and shuddering

from the fourteen teats into the fourteen mouths sucking

and blowing beneath them:

the long, perfect loveliness of sow.

For me, this poem is like drinking fresh juice. My body knows it is good. It reminds me of something I have lost that is waiting to be found. It reminds me that blessings are to be found here on earth, that they are in fact, all around me, and even, in me.

Like the sow, we are creatures of the earth. We have our spines, our fodder, our slop. Our perfect loveliness does not depend on transcending these things but is present in our earthiness, in our contradictions, scars, and coarseness. We too deserve blessings of the earth on us.

In the poem, it is St. Francis who reminds the sow of her loveliness, but this is so she can remember, so she can again flower from within of self-blessing.

So for me, self-blessing is an act of self-kindness, of reminding myself of my own goodness despite ways that I appear ugly to myself. Sometimes this requires a leap of faith – an openness to the possibility that I am in my heart good despite the fact I don’t feel that way at all.

Self-condemnation – telling myself there is something wrong with me – is an old habit, a well-worn path in my brain. It takes force of will to remind myself to self-bless. It is a discipline, a remembering again and again that beneath my fear and the ways I harden myself is my own heart both strong and broken.

How to choose a therapist

The first thing to know about choosing a therapist is that you should like your therapist. A big part of what helps people in therapy is their relationship with the therapist. A relationship grows over time, but when you start therapy, you want to have a good feeling about the therapist and your ability to trust him or her. It is important to trust your gut here. If you have a bad feeling about someone, or a kind of neutral feeling for them, I would suggest you try someone else. I am not saying you should love and wholeheartedly trust your new therapist after one session, but you should have the gut sense that this a person, who in time, you will be able to trust to know the parts of yourself you keep hidden from most of the world.

To this end, I think it makes sense to view a first appointment with a therapist as a trial session. If this first session doesn’t feel right, then move on to another therapist. Sometimes it may take more than one session to make this decision. Now seeing a few therapists before you find the right one could cost you some time and money. Of course, you probably want to get down to business and feel better/work on yourself/grow but taking the time to find the right person is crucial. You are engaging in therapy to make some change in yourself. This is important business and in the long run it will be cheaper and quicker to find the right therapist rather than start therapy with someone only later to discover that you don't work well with this person.  

I want to repeat one point here: Trust Your Gut! If someone doesn't feel right to you, trust that. Choose wisely. Don’t settle. Not every therapist is right for every person. Keep going until you get the sense that you have found the right person.

A word about money:

Therapists have a stated rate, but most also work on a sliding scale. It is standard practice to ask therapists if they have a sliding scale. A therapist's rate is usually up for discussion, however, be prepared to talk to the therapist about your financial situation and the role that money plays in your life. The therapist will likely view the conversation about the fee as part of the therapy.    

If you don't have insurance, and the therapists in your community have sliding scales that you can't afford, you can likely find low-cost therapy through graduate schools or community-based organizations in your community. To find graduate schools use the search term "psychology graduate program" "mft program" and "msw program" and the area you live in (ie. “psychology graduate program san Francisco”). Visit program's websites and see if they have a low-cost clinic. Some community based programs to check out are Catholic Charities and Jewish Family Services (these organizations serve people of all faiths and/or no faith).

You need to be able to afford therapy. But don't just go to the lowest-cost therapist you can find. Find the person who is right for you. Therapists who charge more usually have more experience. This is a plus, but it doesn't mean a new therapist can't be helpful to you.

How to find a therapist

Like most things in life, one of the best ways to find a therapist is to talk to friends and family. Ask people who you know who are in therapy who they see and if they have benefited from the therapy. Another option is to ask friends who are in the mental health field for a recommendation. If neither of these options is available, the web is a good place to find a therapist as many therapists have websites. Check out the site and see if you like what the person has to say about how they work. Visit a bunch of different therapists' sites so you can compare. Again trust your gut.  

Qualifications and training

First, know that it is perfectly acceptable to ask about a therapist's training and their experience working with people who are struggling with what you are struggling with. However, most therapists are generalists. That means that they work with people with a range of problems and life circumstances. So it is usually not necessary to find someone who is a specialist in your problem area but you also want someone who has some experience with what you are dealing with.

There are hundreds, perhaps thousands of types of therapy and it is well beyond the purview of this article to talk about this variety. Research has shown that, in general, therapy works and also in general, that one type of therapy is not better than other types (there are exceptions for certain problems, however). Furthermore, most therapists don’t practice one type of therapy, but instead combine different elements in their work. I suggest you ask the prospective therapist about his approach to therapy and get a sense if this is a fit for you. If you are a very spiritual person, you may want a therapist that includes this element in her work. If you a very logic driven person, you may want a therapy that relies heavily on rationality (ie coginitve-behavioral therapy). Include trauma.

What do those letters after the therapist's name mean?

There are a bunch of different degrees that allow someone to obtain a license from the state that allows them to practice psychotherapy. I am providing this information because people can be confused by this subject, but having one degree versus another is not a way that I distinguish who is a good therapist and who is not. My recommendation is to make sure someone is licensed by the state to practice psychotherapy and then to forget about the letters after their name. That said, here is what those letters mean:

Psychologist (Phd, Psyd, Edd) - Psychologists have a doctoral level degree. Traditionally, to be a psychologist, you had to go to a Phd program and learn how to do research.  The Psyd degree came into existence in the 1970s due to demand for more clinically-focused training. The Edd degree is less common and denotes that the psychology program was housed in an educational department of a university.

Social worker (msw, lcsw) Social workers have a master's degree. Msw is the degree you get when you graduate and lcsw is the letters you put after your name after you are licensed by the state to practice. Social work training often focuses more on learning how community systems help people.

Marriage and family therapist (Mft) - MFts have a master's degree. Their training ensures that the person has experience treating adults, children, and families.

Psychiatrists (MD) - These days most psychiatrists prescribe psychiatric medicines, but some still practice therapy. Psychiatrists went to medical school where they learned to be general practitioners and then went on to specialize in psychiatry.

A client teaches me about letting go

“Have you ever read the Dice Man?” Ana asked.

Ana is my client. She is a woman in her mid-twenties just getting out of a passionate and tumultuous relationship. In the wake of the break-up she has been thinking about excitement and attraction vs stability and safety. Like most people, she wants both but has found it difficult to find the balance.

  

The Dice Man is a novel that was fashionable in the 1970s about a bored psychiatrist who begins making decisions based on the role of the dice. His method is to write out a list of options and then let the dice decide which one to take. Thus, he controls the parameters but the dice ultimately make the decision. The theory is that by listing options that you wouldn’t normally choose along with more conventional choices allows expression of parts of the personality that you usually doesn’t allow to see the light of day.

“Yeah, I read it,” I said.

“What did you think?”

“I’ve used the dice to determine what I do on a Saturday night, but I don’t recommend making major life decisions this way.”

“The Dice Man wasn’t reliable.”

 “No, he wasn’t. He left his wife because the dice told him to.”

“I want someone who is reliable”.

“But you knew that [dude she broke up with] wasn’t reliable from the beginning.”

“Yeah, I know.”

“The thing is I don’t want to always have to be reliable. I mean I am reliable. I was brought up this way. But what if I don’t always want to be there for the other person?”

Ana was wrestling with seeing life in grays instead of in black and white. There are parts of her that crave safety and reliability in a man, and other parts that want passion and wildness. Similarly, there are parts of her that like to be reliable and others that want to be wild and unpredictable.

“The crazy thing,” she said, “is that I have been watching myself and I can change pretty drastically in the span of a few minutes. This morning I felt sad about the break-up for a while, but I didn’t fight it and it went away.”

“Sounds like you are judging yourself less.” A few weeks ago, I pointed out to Ana how often she said she shouldn’t feel how she was feeling. I suggested dropping the shoulds and experimenting with letting herself experience her feelings more.

“I think of it as letting go,” she said. “You know, today I had this experience with this girl I work with. She is someone who I have felt like a mentor to. I am a little bit older, and I have worked at the job longer.  But now she got into law school which I have been thinking of applying to for a long time. And she got a date with this guy at work who I think is cute. I have been thinking about making a connection with him for a long time, but I just never did it.”

“How did that feel?” I hate this question, but sometimes it is appropriate.

“It’s funny. Normally, this would get me down. I would feel jealous. I would feel like I should have done what she did. But today it just struck me as kind of funny.”

“Funny?”

 “Yeah, like I just didn’t take it so serious. She used to look up to me, and now life has us switching roles.

“The student has become the master.”

“Yeah.”

There had been a similar yet subtle shift in the roles between me and Ana. By accepting her experience and lightening up, she was teaching me to do the same. Learning from clients is one of the best parts of therapy, but it also brings up some anxiety about roles.  Should I be accepting money from someone who is teaching me?

Feeling more like a chatty friend having a philosophical conversation than her therapist, I said, “Have you ever had the experience where you feel really attractive and cool and then later in the same day something happens and you feel like a loser?”

“Yeah. But I am feeling less hung up on it. And being the loser isn’t all bad. When I feel like a loser, I don’t experience so much pressure.”

“We can’t be winners all the time, and it is stressful to try to always be at the top.”

“No. And letting myself be both…it feels so more peaceful.”