Mindfulness

Because so many of the people I see experience debilitating anxiety, no matter what else complicates their lives, I have been interested in increasing the options for relaxation that I have available for patients.

Jon Kabat-Zinn has written several clear and simple books about mindfulness and meditation, which I like. Here is a YouTube example of a mindfulness exercise narrated by him. And although I like his work and he seems like a wonderful human being, as one comment on another YouTube video of him said, "I don't think it's bad if it gets you excited about the message, but after the excitement has passed, you're left with nothing but the application of that message, because you can't do anything with the messenger but to worship him. Which is pretty useless to begin with." In my experience, the most difficult part of mindfulness is actually practicing it.

Here is a posting of several everyday, ordinary mindfulness practices that I am going to try this week:

1. Mind your feet while you’re grocery shopping. (my yoga teacher)
2. Mind your chair while you’re typing.
3. When going through a door, think ‘I am I’ (Fourth Way exercise)
4. When putting on your shoes, try and put on the one you usually put on second first. (also Fourth Way, Ravi Ravindra)
5. Drink your tea without sugar if you’re used to sugar in your tea. If you’re used to no sugar, just once put in sugar. Works with coffee too obviously. The point is, like the previous one, to become aware of patterns and how hard it is to break them (Jiddu Krishnamurti). The point is NOT to change the pattern. A new pattern is just as much a pattern as the old one. Just create a bit more flexibility.
6. When you have to wait for something (grocery line, pc starting up etc.) breath consciously.
7. Cleaning the house: be aware of every step of cleaning.
8. Keep a diary of your thoughts and feelings. The goal isn’t to create literature, but to observe. So don’t mind repetition.
9. Notice… take a deep breath; notice five things you can see. notice five things you can hear; notice five things you can feel (shoes, pants, hair against forehead etc.)
10. When you’re annoyed at waiting for a stopping sign, or anything else for that matter, just SMILE (Thich Nhat Hanh, Zen Buddhism)

Back to Work

I started seeing people in my office last week, and this week I'm back up to my regular schedule at both sites. It's great to feel well (if still a little sore in the abdomen area). By the end of my recovery I really missed my patients and working. Planning and thinking about returning to work has been a good motivator to get out and walk for exercise, take my meds, and deal with whatever complications, so that I could get back to my regular life. I feel very fortunate to be able to do that.

I've started to do my Daily Gratitudes again (from Martin Seligman's positive psychology):

Keep a gratitude list. Write in your journal or therapy notebook three things every day that you are grateful for, that went well, or that make you happy. For an added bonus, share the daily list with a loved one.

Most days lately include gratitude for good health.

Health and Recovery

As you may already know, I'm out of commission for a few weeks because of health problems. In early July I was diagnosed with endometrial cancer, and had surgery last week. Biopsy results indicate that the cancer had not spread, the surgery was successful, and I should need no further treatment.

Unfortunately I've had a few post-op complications which may postpone returning to work for a week or two. I have learned why medical consumers are called "patients," because patience is certainly what is required!

I am feeling quite well--except for impatience--and as a result of this experience have made many resolutions about improving my health habits.

Here's to health and happiness for us all!

The Worry Thirty

This exercise if for anxious people who find themselves worrying about things to the detriment of quality of life, concentration on their work, and/or getting to sleep at night.

Rather than thinking about everything you need to worry about throughout the day and into the night, choose a thirty-minute time period that is not directly before bedtime, and sit down to get your worrying out of the way for the next 24 hours. Now is your chance to worry thoroughly and completely about every anxiety, concern, and fear that you face. The first step is to make a list identifying each of your worries. Take a sheet of paper and write as follows:

1.
2.
3.
...etc. up to thirty worries.

Once your list is absolutely complete (make sure not to leave anything out), review each worry. Consider every possible consequence of what you're worried about--including the dire, extreme, and catastrophic. Worry hard. That is what you are doing right now. Then when your thirty minutes are up, fold the list and put it away somewhere safe--in your pocket or purse, or at your desk or nightstand. You still have the list, so there's no danger of forgetting anything. But now you're done with worrying for the day, and can go on to living the rest of your life.

The Essential Bibliography

Here are my favorite books for dealing with depression and anxiety:

The Feeling Good Handbook by David D. Burns, MD. It's jam-packed with cognitive behavioral techniques for dealing with depression, and can't be digested all at once, but is a good resource.
For people who have been through at least one course of therapy for depression, Undoing Depression: What Therapy Doesn't Teach You and Medication Can't Give You, by Richard O'Connor, Ph.D.

For anxiety in general, and specific anxiety disorders, "The Anxiety and Phobia Workbook" by Edmund J. Bourne, Ph.D.

For emotional distress and lack of coping skills, a book I really like, even though it was written especially for people with Borderline Personality Disorder: "The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotional Regulation & Distress Tolerance": by Matthew McKay, Ph.D., Jeffrey C. Wood, Psy.D., and Jeffrey Brantley, MD. I particularly like this book because of how accessible it is. I have been practicing some of the skills it suggests since I began reading it and using it in therapy.

Overview of Anxiety

Anxiety disorders can be difficult to understand and treat because they seem to operate in a paradoxical manner--sometimes the more aware the person is of the anxiety, and fighting it, the more intractable it seems to grow. The reasons for this are clear, however, when anxiety is viewed in terms of reinforcement theory.

Anxiety involves mental and physiological autonomic nervous system arousal in reaction to a feared stimulus. The person soon learns that by avoiding the stimulus, he or she is released from the anxiety. This is negative reinforcement for avoidance. The person will continue to avoid the stimulus, and continue to be reinforced (by the relief from anxiety) for that avoidance.

Unfortunately, reaction to anxiety-provoking stimuli tends to generalize. Soon, other similar stimuli are avoided. Even thoughts, memories, or indirect reminders may be avoided. The person's life becomes constricted and restricted by everything that must be avoided in order to stay anxiety-free--and eventually that doesn't work either, and the person may feel anxious at even the remote possibility of encountering the stimuli.

Treatment in one way or another interrupts the cycle by removing the reinforcer. In other words, the person must not avoid the anxiety-provoking stimulus any longer. this does not have to be done all at once--in fact, systematic desensitization, probably the most widely used technique, involves incrementally introducing exposure to thoughts of the feared stimulus and waiting until there is no more anxiety before moving on to the next small step. Other techniques such as flooding or implosion, which involve prolonged exposure to the stimulus, should be done only with care and caution and in absolute safety, with plenty of time to "decompress" and process the experience. But all techniques boil down to facing the feared stimulus rather than avoiding it.

The physiological state of extreme anxiety cannot be maintained for long periods of time. As the person faces some form of the stimulus in a controlled setting and lives through the anxiety in safety and without harm, the autonomic nervous system essentially shrugs its shoulders and says, "oh, what's the point in getting so upset."

Relaxation skills are essential in dealing with an anxiety disorder. Some cautions are in order. Actual exposure to the anxiety-provoking stimulus should be done only in a safe and controlled setting. the person should not leave the anxious situation without using relaxation to bring the anxiety down to acceptable levels. If the person leaves while still feeling anxious, then the avoiding behavior has been reinforced again and the problem becomes worse. The person shouldn't give up if they seem to backslide, however; but move back to an earlier step.

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More on Religion and Depression

The group blog Segullah is continuing its series on depression, with Part IV: Family Ties and Part V: Parenting Children with Depression. I found the discussions sensitive, knowledgeable, and hopeful. The participants talk about other disorders as well, such as Bipolar Disorder and Obsessive Compulsive Disorder. The comments after the discussions are detailed and helpful.

When Relationships Go Wrong*

Dealing with Depression

I have recently noticed some very good roundtable discussions about depression on some of the Mormon blogs. The first two were moderated by Kathryn Lynard Soper, on blogs Segullah: Part I; Part II; and Part III, and By Common Consent: Overview; Part I; Part II; Part III; and Part IV. Here's a post and comments about Post Partum Depression on Feminist Mormon Housewives.

I'm glad to see people talking openly about cultural contributors to depression and sharing ways they deal with depression successfully.

One More Rule

This from my colleague Tammy Heaton, LMFT, an addition to the Gottman-Rapoport Intervention(TM), as a guide for couples working through conflict:

"When _________________ happens,
I feel_________________________,
I think (perceive) ________________,
I want ________________________."

The Rules...*

...For Constructive Conflict

Goal of Conflict: heal emotional wounds and learn to process fights and regrettable incidents.

1. Take turns as Speaker and Listener. There are two subjective realities, and both are right.

2. Eliminate the Four Horsemen of the Apocalypse:
Criticism: of personality, identity (antidote - a gentle start-up)
Defensiveness: manifests as counterattack or playing the innocent victim (antidote - accept responsibility)
Contempt: speaking from a superior place (antidote - build a culture of appreciation and respect)
Stonewalling: shutting down because of physiological overload (antidote - learn self-soothing and take breaks)

3. Start as neutrally as possible. Both must feel safe and open. Both must down-regulate physiologically, and interrupt the discussion if heart-rate goes up, etc. Empathy, rational thought, and ability to communicate vanish in the fight-or-flight mode.

4. "What's this?" attitude vs. "What the hell is this?" attitude.

5. Speaker's job - no blaming, use "I" statements, state feelings and positive needs. State position without blame, with depth and background.

6. Listener's job - take notes, summarize and validate Speaker's position. Ask questions about the history and deeper meaning in the partner's position. Validate emotions even if disagree with position.

7. Postpone persuasion and problem-solving until both people can state his/her partner's position to the partner's satisfaction.


Six Skills to Develop and Use During Conflict:
1. Soften startup
2. Accept influence
3. Make effective relationship repairs during conflict, and accept repair attempts from partner.
4. De-escalate conflict (take breaks)
5. Compromise
6. Physiological soothing.


*based on a John Gottman workshop I recently attended

Temple Grandin

I've been interested in Temple Grandin since first reading about her in Oliver Sacks' 1995 book "An Anthropologist on Mars." Watching this clip of her speaking moved me so much that I cried for 20 minutes afterward (and I don't usually cry). I've worked with autistic and Asperger's clients over the years. To make an over-generalization, they're like Jesus' friend Nathaniel, in whom there is no guile.

There's a new HBO movie starring Claire Danes about her early life, which I haven't seen yet, but which looks good.

An Analogy

I am still thinking about the different ways our culture responds to assaults on property and (sexual) assaults on person. Consider the following situation:

A woman takes her purse and goes shopping, perhaps with the intent to buy something. Or maybe she is just window shopping. Maybe she hasn't made up her mind yet about whether or not she wants to buy. She goes into a store and looks at the things for sale. Maybe she takes something from the shelf or off the rack and looks at it. Perhaps she even carries it up to the shopkeeper at the checkout counter and takes out her money.

But then she changes her mind and decides she's not going to buy the item after all. The shopkeeper grabs her purse away from her and steals her money.

He's completely justified, of course:

1. She shouldn't have been shopping if she didn't want to buy.
2. She went into his shop, didn't she? Doesn't that mean she wants it?
3. She had her purse right out in the open where everyone can see it--a definite signal of intent to buy.
4. Once she's in the shop with her purse, after she's examined the merchandise, and especially after she's taken out her money, too late! Nobody could expect the shopkeeper not to grab the money at that point. He's way too far into the sale to quit now, even if she changes her mind. Sellers can't be expected to control themselves then.
5. It's just she said/he said what really happened anyway.
6. And we all know how these shopping women are--basically asking for it.

Tell me how "date" rape is different from this.

The Stages of Change

Here is a good article by Marc F. Kern about Prochaska's Stages of Change model for overcoming bad habits, addictions, and compulsive behaviors. The 12 Step program is the gold standard, but for some people (and some problems) a harm reduction approach rather than a total abstinence approach may be more effective. I'm not a specialist in chemical dependency or substance abuse, and won't get into that battle, but this model seems a common-sense way to navigate the almost inevitable mistakes and relapses involved in overcoming a long-standing habit.

The idea behind the SCM is that behavior change does not happen in one step. Rather, people tend to progress through different stages on their way to successful change. Also, each of us progresses through the stages at our own rate.
....The stages of change are:

• Precontemplation (Not yet acknowledging that there is a problem behavior that needs to be changed)

• Contemplation (Acknowledging that there is a problem but not yet ready or sure of wanting to make a change)

• Preparation/Determination (Getting ready to change)

• Action/Willpower (Changing behavior)

• Maintenance (Maintaining the behavior change) and

• Relapse (Returning to older behaviors and abandoning the new changes)

....Transcendence

Eventually, if you “maintain maintenance” long enough, you will reach a point where you will be able to work with your emotions and understand your own behavior and view it in a new light. This is the stage of “transcendence,” a transcendence to a new life. In this stage, not only is your bad habit no longer an integral part of your life but to return to it would seem atypical, abnormal, even weird to you.

When you reach this point in your process of change, you will know that you have transcended the old bad habits and that you are truly becoming a new “you", who no longer needs the old behaviors to sustain yourself.

I read once that to successfully kick an addiction the average person goes through rehab seven times. I don't know if that is true, but it speaks to the difficulty of change, and to the importance of self-awareness and honesty about where one is in the change process.