The comfort of the cage

The other day I was running around Lake Merritt in Oakland. It was sunny, the sky was, well, sky blue with no clouds. The light was glimmering off the waves and a cormorant flew low over the water. My Oakland peoples were out running and walking their dogs. It was Springtime and life was in the air.

But I didn't care. I was worried, and I kept thinking about whether she was going to call. I would only feel better if she called. Or should I call her? Should I be honest and upfront about my needs because that is who I am, honest and upfront? Or should I play it smart, let her come to me, knowing that this strategy is probably more effective?

All of a sudden, I got pulled out of this tizzy of thinking and I realized where I was. I saw the water shining, I heard the rhythm of my footsteps, I smiled at a guy running in the opposite direction. I felt a part of this day, connected to the lake and the sun and the other people. I felt alive!

And then I remembered I was worried, and just as suddenly, I was back in my anxious little head, worrying and strategizing. As unpleasant as it was, it was as if a part of me actually preferred the worried thinking to the freedom of letting go.

This part of me said, "hey, yeah I know you are digging on the scene and and the sun and the lake and just being and all, but you have a life to worry about, so get back to worrying, bitch". And like a good bitch, I obeyed, worrying my little head off the rest of the run.

This is what I call the comfort of the cage: when we actually choose a crappy state of mind over a more free state of mind because somehow feeling good is scary and feeling bad is safe.

In my experience, there are three reasons we do this:

1. We are scared to not think about our lives. We feel like something bad will happen if we are not worrying, planning, analyzing. "Can't let go into the moment, because then the house of cards might topple". This is what happened to me when I was running around the lake.

2. Feeling good is scary because we might lose it and feel bad again, so instead of dealing with this fear, we decide to just get it over with and feel bad again. This happens a lot with people who are starting to get better from depression. They are so scared of falling back into depression that they can't enjoy the new, good feelings and end up exactly where they don't want to be - depressed again. It's like flying feels really good, but shit, I might crash, so I better go ahead and just land the plane.

3. We find ourselves feeling really good, and then part of our brain wants to figure out exactly how we got here, so instead of just enjoying, we start thinking again, and dammit, the good feeling is gone. This one happens to me sometimes during meditation. It's hard for me to enjoy the new scenery, I want to go back and create a map.

In each of these instances there is the underlying sense that uncertainty is unbearable, and we actually prefer unpleasant states of mind that we are familiar with to the uncharted terrain of being more alive to the moment.

I don't know of any foolproof tricks to stay in the moment. I just keep reminding myself to let go, that it is ok to get out of my head and enjoy what life has to offer. Maybe one day, I will no longer be my mind's bitch.

What about you? How do you get out of your head and let yourself be in the moment?

Note: You can now subscribe to get new blog posts by email, that way you don't actually have to visit the blog. Just put your email address in where it says Join Our Mailing List. Hopefully this goes without saying, but I would never, ever sell or give your email address to someone else or use it for anything other than mailing you new blog posts.

 

A Happy Relationship with Alcohol

Drinking too much will mess up your life. It will rot your liver, hurt your self esteem, get in the way of your relationship, destroy friendships, even cost you your job if the problem goes too far. 

Nothing new here.

Recently though, a friend told me a reason I never thought of for making sure I keep my relationship with alcohol healthy: If drinking becomes a problem, I may have to stop drinking. That would suck, because alcohol is fun and part of my sane lifestyle. Hell, I’m on a plane right now enjoying a Jack on the rocks. The alcohol makes my space invading neighbor’s elbows more tolerable and keeps the reality that a few inches below my feet is 37,000 feet of air pleasantly fuzzy.

As you can probably attest, alcohol has a great variety of uses including lowering inhibition, decreasing awkwardness, and increasing fun. It enhances meals, improves conversation, and makes cooking more enjoyable. Plus, mixing drinks can be a creative and tasty art.

But if you drink too much, you sacrifice all this. When you realize you have a problem, you will have to cut down. Then, you will no longer have license to get drunk. See, if your drinking is under control, every once in a while, in the right situation, with the right people, its fine to get a little ripped. But once you have a problem, you loose the right to get drunk. Now you probably shouldn’t have more than two, because well, you know what happens once you start down that road…

And if things get really bad, you will have to give up drinking all together, and forever. You will have to dance, go on first dates, attend weddings, reunions, and family functions completely sober. And then even if you have one drink, you will have relapsed. You will feel bad about yourself and have to go acknowledge what happened at a meeting.

You don’t want this. You want to be able to drink and have it be a good thing not a bad thing. So, keep it under control. Find other ways to cope with stress, so alcohol is not your go to stress reliever. Don’t drink every day. Make alcohol an addition to fun times, not the point of fun times. For college-aged readers: don’t funnel, shot gun, use a beer bong, or engage in drinking games – this is dumb. Only get drunk once in a while and then in circumstances where you are with people who won’t take advantage of you and where you don’t have to drive.

With a little maintenance, you can enjoy a lifetime of happy times with your good pal, booze.

How did that make you feel?

"How did that make you feel?" is such a cliched therapy phrase that I try to avoid asking anybody this question.

On the other hand, "how do you feel right now?" is often therapeutic gold.

I was halfway through a first session with a woman in her mid thirties. As a therapist, I am trying to do a lot in that first hour: understand who this client is, identify why they are coming to therapy now, rule out any emergency conditions, and above all, establish rapport. The session started well, but when I began asking her more questions about her marriage, the vibe changed. It was almost as if we were arguing a little bit, me curious about her marriage, her not wanting to go there.

"It's not my marriage, I've been sad for years before this."

I tried to explain how relationship dynamics can reveal how people relate to others in general, then I backed off. I was getting heady, a bad sign. I remembered one of my favorite therapist acronyms - WAIT - Why Am I Talking? 

"Ok. You've been sad for years..." I said. Neither of us was sure where to go next.

"How do you feel right now?" I said.

"I feel anxious. I hate feeling this way."

"What happens if you let yourself just feel anxious without trying to push it away?"

She didn't want to do this, but I convinced her to try it for 30 seconds.

"Now I feel sad."

"How is that?"

"It's better than feeling anxious. I feel calmer."

The whole vibe in the room had also changed. I felt calmer, less frenetic. I felt like my energy had come down from my head and into my body. The rest of the session flowed with a natural rhythm.

Feelings can sit on top of other feelings. They call this primary (underneath) and secondary (sitting on top) emotions. Particularly when someone is anxious, there is often another feeling underneath. Even though the primary emotion is probably something difficult, it almost always feels better when it has a chance to breathe in a safe environment.

This is something I practice myself when I feel all jumbled up inside. I find a quiet place and let whatever it is I feel just be there for a while without pushing it away and without trying to figure it out with my head. Usually, in time, the mud settles and I can see a little more clearly what is actually going on inside me. This doesn't "fix" the problem, but seeing clearly is often the first step to fixing something.

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.