Depression Treatment Without Medication

I frequently get questions about treatment for depression without using medication, or going off medication for depression without relapsing. I’m going to summarize what I know and give my point of view about this.

First and most importantly, nothing said here is treatment or a substitute for treatment. Major Depressive Disorder and related disorders can be life threatening. Prior to Covid-19, suicide was the tenth leading cause of death in the U.S. and for people in younger age groups ranks second. If you are feeling suicidal please contact the national suicide helpline at 800 273 8255 or in the San Francisco Bay Area (number reachable from anywhere, of course, but I want you to know what time zone it is in) 415 781 0500, both available 24 hours a day.

My experience with suicidal clients is that people can and do recover from suicidality and go on to have lives that are fulfilling– something that the person actually wants for themselves. My experience with people who completed suicides is that all of them were missed and grieved by loved ones. I can’t emphasize either of these points too much.

Equally important, if you are on medication do not make medication changes or go off medication without consulting with your prescriber and having a plan.

Here’s a quick list of topics covered:

  • Talk therapies including–
  • Cognitive and Cognitive-Behavioral Therapies
  • Mindfulness and Mindfulness based Cognitive Therapy
  • Interpersonal Therapy
  • Exercise
  • Diet, especially certain nutrients
  • Thoughts on why DIY treatment may fail
  • Light therapy for SAD
  • Electrical stimulation therapies

I will not cover every topic in equal depth.

First, my point of view: medications may be necessary for successful treatment. Don’t reject them out of hand. At the same time, medications alone may be insufficient for successful treatment of depression, don’t reject other forms of therapy and don’t reject a broad based approach to treatment. Your life is not a science experiment; you want to get better. At the same time, medications may not be necessary for treatment but for that to work, you will have to be a lot more proactive in your approach to getting better. All these reasons add up to the main one which is that you should do this with a treatment professional, possibly with both a talk therapist and a psychiatrist, possibly other providers depending on your individual case.

Now let’s talk about non-pharmacological interventions for depression. The most obvious one is talk therapy. There are several types of talk therapy that have been evaluated for depression including Cognitive Behavioral Therapy, (CBT) Mindfulness Based Cognitive Therapy, and Interpersonal Psychotherapy. Interpersonal Psychotherapy is structured for relatively brief treatment and has been widely adapted for use, including by the World Health Organization. It is designed as a time-limited treatment and focuses on interpersonal issues, as the name indicates, and social functioning. It is considered an evidence based treatment and has been shown effective in studies.

There is research that has demonstrated that CBT can be equal to medication in treatment for depression. There are caveats to this– a cognitive therapist may have greater or lesser degrees of skill in providing treatment, whereas the uniformity of the medication is highly likely to be the same at every pharmacy. On the other hand, people who go off medication are more likely to have depression relapses than people treated with cognitive therapy. Probably the best known cognitive therapy book for general consumption is The Feeling Good Handbook by David Burns, MD. My experience with providing cognitive therapy is that although it can seem very simple and obvious to learn about the most common forms of cognitive distortions, it can be surprisingly hard for people to learn to spot them in their own thinking. After all, everything I do turns out badly. That’s not a cognitive distortion, just a fact, right? It can take a relatively protracted conversation with a therapist to discover that one has, perhaps, succeeded at something at one point in life and the statement is an example of all or nothing thinking.

There is also mindfulness based cognitive therapy of depression (MBCT) which has been shown to be helpful. My observation is that depression tends to focus on the past while anxiety is focused on the future. Mindfulness, of course, keeps focus on the present, which means that whatever I’m depressed about (or anxious about), there’s a lot less mental room for it to happen than when I include my entire past and my entire future– If only I had behaved better when I was in first grade! And what about the heat death of the universe billions of years from now… There are reports of people having negative experiences from doing mindfulness so that suggests one should not simply jump into mindfulness for depression without a therapist or meditation teacher. I have introduced clients to basic mindfulness practice with few to no negative effects reported, but that’s clinical experience, not a clinical trial or study.

Regular exercise and a healthful diet can increase a sense of self-efficacy

There have been studies of exercise and depression, and it’s not surprising that there have been positive results. At a presentation I attended, representatives of the UCSF Depression Center were willing to specifically name walking and yoga as two practices shown to relieve depressive symptoms. I have not done a separate web search looking for studies. Interestingly, I had a clinical experience with a client who discounted exercise for depression saying, “It didn’t work. When I stopped walking I got depressed again.” No one has ever been surprised that when they went off medication depression returned, and we should remember that these kinds of interventions are likely to require regular practice to be of greatest effectiveness. I will discuss this more a little later.

A variety of research studies have suggested that diet may have an effect, especially supplementation with folate and omega-3 fatty acids, found in Salmon, walnuts, and other foods. There has been research into the role in vitamin D and its association with depression also. Many people have vitamin D deficiencies– I once asked my primary care doctor if I should be tested for a deficiency and his answer was, “No, everyone’s deficient. Take a supplement.” Another doctor I knew who was a child psychiatrist who did test his patients said that something like 95% were vitamin D deficient, but we are next to the ocean and get a lot of gray days.

Other research suggests that the gut biome has an influence on depression. The UCSF Depression Center is willing to recommend folate and omega-3’s for depression, but nobody is promoting dietary changes as a stand-alone treatment. The thing to be mindful of is that folate is found in leafy greens and is a water soluble vitamin. As such, if you stop eating your vegetables your levels will drop rapidly and any beneficial effect is likely to also drop equally rapidly. Omega-3’s, being more fat-based probably last longer in your system but again, ceasing to consume the foods or supplements will lead to the benefit disappearing. Vitamin D is a fat-soluble vitamin as such probably lasts longer in the system, but nothing lasts forever. The gut biome stuff that I’ve read leads me to think that it’s about getting fiber, but that research is a lot more complex. I’m not trained as a nutritionist and don’t claim special knowledge in this area.

So here’s the thing about diet and exercise from my point of view. Some of the practices have pretty good research support for being specifically helpful with depression. When you look at them from a more general nutrition point of view, getting more leafy green vegetables is clearly a recommended dietary practice, omega-3’s are recommended for a variety of potential health benefits, exercise also is known to have a wide variety of health benefits, so any time we start doing these with a specific goal of helping depression, we’re supporting the general goals of better health and improved self-care. There’s a clear cognitive and behavioral aspect to this– “Look! I’m taking better care of myself! I can effect positive change in my own life!” One label for this is self-efficacy. Another is self-compassion. It’s something that’s under my own control, and when I’ve done it, nobody can take it away from me.

If it’s all that easy, why is depression such a huge health problem? Lots of reasons, obviously. Let me give a brief clinical perspective. One thing is that none of these non-pharmacological interventions has immediate strong effects. Neither do antidepressant medications either, given that most of them take weeks to kick in. A trainer whose lecture I attended once pointed out that people going into detox for alcohol are mostly depressed, and that three weeks off alcohol would lift the depression for most of them– which is also the amount of time it takes for a lot of medications to take effect. So he always recommended what he called “a clinical trial of abstinence for depression” before putting anyone from detox on psych meds. Similarly, changes to diet, exercise, and general lifestyle take time to kick in, so it may be very difficult for someone attempting to self-treat for depression via the diet and exercise route to see progress, leading to a lapse in the lifestyle changes and a relapse to depression.

The other factor is that one of the most problematic symptoms of depression is what was labeled by one of my clients as “that feeling of… I don’t wanna.” If you like more sophisticated language you can call it motivational deficit. This is where feedback from a therapist can help kick start and maintain the change process. Behaviorism works by giving positive reinforcement to successive approximations of the desired behavior. The role of the therapist is to spot the approximation and reinforce it when the client may have discounted it. Client: “I didn’t exercise. All I did was go to the store.” Therapist: How did you get to the store?” Client: “I walked.” Therapist: “So you not only got out of the house and walked to the store, but you also got some groceries. That counts as exercise and self-care.” I knew a client whose discounting was so powerful that they could convince an entire therapy group plus an intern that they had done nothing for themselves when I was able to honestly and factually point out at least three things they had done for themselves that were part of their treatment goals.

Treatment works!

For completeness I am including a couple more non-pharma interventions

There is light therapy for SAD (Seasonal Affective Disorder). I do not have clinical experience with this but have known people socially who lived in the Pacific Northwest and had good experience with it. This takes getting a for real diagnosis by a licensed practitioner and using a specially designed light source, usually in the mornings.

There is also transcranial magnetic stimulation and electroconvulsive therapy along with other brain stimulation therapies. I am including a link to these as they are non-pharmacological in nature, but the last time I read up one still had to fail at getting relief from medication to become eligible. Electroconvulsive therapy is still used in severe treatment-resistant depression. It has bad associations from misapplications and involuntary treatment that happened many years ago, but is no longer in use except on a voluntary basis. None of these are available as DIY projects for obvious reasons.

Photos copyright James Matter 2021

Posted in behavioral health, cognitive therapy, Depression, mental health, Uncategorized | Tagged , , , , | 1 Comment

Don’t Ask Why– There are Better Questions

Someone recently asked me, in effect, “why am I so messed up?” This was the essence of my answer:

A way forward…

Wrong question to ask. Ask yourself the following questions: how do I want to act in the various different circumstances I have in my life? What are the barriers, both internal and external, to behaving the way I want? How do I remove those barriers? Do I need outside help to remove the barriers and if so who do I recruit to help me make the changes I have in mind? What’s the first, easiest tiny baby step I can make that will take me in the direction I want to go? Map out a change plan for yourself, break things down into small steps you can do, and you will become more like who you currently wish you could be.

Take doable steps

In a long career of working with people who had big problems, I have seen so many inspirational lives that I am humbled. People who on the surface look like ordinary folks living unexceptional lives have come from incredible psychological and physical hardships just to have a job, a place to live, food, and a few friends. And don’t forget health care of both the medical and psychological kind. Ultimately, all of them had a plan on how to have a better life. Generically, it was the plan outlined above. For each of us the details will be different– sometimes radically different– but will distill down to the steps in that paragraph.

I have been coming back lately to something that a wise professor taught in my “how to become a therapist” class. Don’t ask why. It’s not an answerable question. It is, however, a transformable question. It can be turned into one or more questions that start with how, where, when, who, what. Let me parse an example. “Why am I so messed up?” Turns into, “When did I start acting messed up?” “What do I mean when I say ‘messed up’?” And importantly, “What would I be like if I was better?” Specifically, “What do I act like and feel like when I’m better?” Also, “How do I get better?” Specifically, “What baby steps that I can do today will help me get better?” See how that works? Notice I’m not promising you will become the person of your dreams. But you will become more like the person you wish you were. And this is the ultra-short version. For a longer, more detailed version, build your own or contact your local behavioral health professional.

Is it the destination, or the start of a new journey?

Images are from Kings Canyon National Park including Sphinx Lakes, footbridge over the South Fork Kings River, and the author’s feet. Photos copyright 2021 James Matter

Posted in behavioral health, change, mental health, Recovery, Therapy processes, Uncategorized | Tagged , , | Leave a comment

Anxiety Management 101

So many people continue to experience anxiety that I have summarized a few of my oft-repeated responses on dealing with it. Many of them also apply to managing negative moods in general.

When in doubt, get professional treatment. Here’s one place to look Behavioral Health Treatment Services Locator for resources in the U.S. Here are some basic tips for managing anxiety:

  • Recognize that a certain level of anxiety is good. Examples— worrying about the weather makes us put on a coat or carry an umbrella, worrying about safe driving makes us wear seat belts and look out for erratic drivers. Worrying about grades makes us study harder. The goal is not to be permanently anxiety-free, but to have appropriate levels of worry about things we can address.
  • Don’t believe everything you think. When we say “I should have…” we mentally create a parallel universe where we made a different decision. Makes for fun science fiction/fantasy movies, but not a happy day. Everything that happens, stays happened. Instead, we can learn from our mistakes and say “next time, I’ll check the weather forecast and carry an umbrella,” not “I should have taken my umbrella.” Or we can even say “I’m always going to carry the umbrella because I hate getting wet.” It can often be not what we think, but how we think it. Shoulda/woulda/coulda thinking is the original “beat yourself up” form of thinking. Stop right now. Don’t say to yourself “I shouldn’t think that way any more.” Just learn to let it go & re-do the thought.
  • Rent your thoughts, or even borrow them. Don’t own them. This is another aspect of not believing everything you think. It’s possible to experience your own internal monologue as dispassionately as you would listen to a podcast or read from a page. How? Mindfulness practice can help. Here’s a lecture from a Buddhist teacher on mindfulness:

  • Learn to relax. There are many relaxation techniques available by looking online. Practice some kind of relaxation technique daily or as needed. It will go better some days, less so some other days. If you listened to the lecture linked above, you will have learned that mindfulness is not a relaxation technique, although many find it to be relaxing. I have a previous post that includes guided imagery/relaxation, which is one of the most widely known and practiced relaxation methods. Weird that we have to learn and practice relaxing, but that’s our world now.
  • Work on living in the now. Mindfulness practice can help with this also. Anxiety/worry is about the future. There are so many ramifications to this that I could write an entire essay about it, but many have been there before me. The DBT formula for this is, “One thing, in the moment, nonjudgmentally” and don’t judge your judgments.
  • Practice self compassion. What would you tell a dear friend going through this? Say it to yourself. There’s also a lot of stuff about this online.
  • Spend time with nature. There are people who suggest that “nature deficit disorder” should be a mental health category. There’s research on how spending time in nature benefits us. If you’re in a nature-deprived urban environment, look for any examples you can find, including the sky, or grass growing through cracks.
  • Get professional treatment. Online advice (including this) is not a substitute for effective assessment and treatment for anxiety disorders and other mental health problems. You may want to become active in advocacy for mental health treatment parity with other health problems as it is often hard to find treatment, unfortunately.

Each of the points raised above is an entire topic, but this is intended, as the title suggests, as a basic starting point. There’s a whole library of books on anxiety treatment/management. Feel welcome to continue the search. It’s definitely possible to feel better.

photos by the author copyright 2021

Posted in anxiety, behavioral health, Distress tolerance, mental health, mindfulness, Uncategorized | Tagged , , | 1 Comment

It Can Be Difficult, I Know– But Relax

I’ve been offline because, quite frankly, I’ve been engaging in as much self-care as needed, and posting here has taken a back seat. But that brings me back to some suggestions that I’ve made many times over the years to other people. One of them is this– taking care of yourself isn’t selfish. If you end up collapsing because you are over-tired and exhausted from caring for others, not only do you become unavailable to care for others, but someone has to care for you. At a time when care givers are pushed to the limit, now’s a good time to not make another case for some professional care giver to handle. If you’re a professional care giver, you need to balance your ability to meet extreme work demands with the ability to show up tomorrow, so while this may work for you, please do whatever it takes above and beyond to take care of yourself.

One of the biggest things that I’ve read about/heard about from people is difficulty handling anxiety, or worry. I realized that there’s an old trick– but still a good one– that I’ve used and guided others in doing many many times. For people who are familiar with DBT, this comes under the heading of taking a mini-vacation.

Get yourself into a comfortable, quiet place. Make sure it is warm enough to sit quietly for half an hour. Close your eyes. Now, think of a safe, beautiful place that you have been in the past or where you wish you could be. If you can’t think of a place from your experience, make one up. Make it someplace warm. Many people enjoy a day at the beach in the summer. Other possibilities could include camping next to a stream with a nice warm campfire, or being in a ski lodge with a big stuffed chair and a warm fire in a fireplace, or soaking in a hot tub– the possibilities are up to you. Now, work on creating as much detail as possible in your mind.

Let’s use the beach example for a moment. Imagine yourself lying on a really high quality beach towel on warm sand. You’ve squiggled and wiggled yourself around until the sand underneath conforms to you nicely. You feel the warm sun beaming down, maybe feel a big straw hat that you have on shading your face. You gently dig your hands into the warm dry sand and think that you have the whole day to just relax. With your eyes closed, you can hear the sound of the waves on the beach, perhaps the voices of children playing somewhere in the distance. Here’s a surprise– someone has a boom box but it’s playing a favorite old song. You think of a line of pelicans gliding low over the water, perhaps smell the salt air, maybe taste a slight aftertaste of the lemonade you just sipped a moment ago. The sky is blue, the ocean may be a blue or a vivid green, with a glassy surface or with whitecaps.

Use your imagination and as many of your senses as you can bring to the imagery. Immerse yourself. On any given time you may want to invite people (real or imagined) to join you in the place you are creating, or you may want to be alone. Always include a detail that allows you to visualize warm hands. This relates to some work that was done on biofeedback many years ago when it was discovered that warming one’s hands was a reliable way to generate a relaxation response. Feeling warm all over is good too, of course, as well as having warm feet and so on. It’s so simple (at one level) and has been around for so long, that numerous comedy sketches have been done about people “going to my happy place.” Well, what can I say? It works, which is why it has become so widely known and so widely parodied. I remember a famous actor talking about how he had become so widely parodied. His response was that it was a kind of honor to be so well known that everyone knew the parody was him. I like that attitude. In this case, I think of what I imagine as a calm, safe place.

It’s so helpful– and easy– to take the mini-vacation. You can make it five minutes or fifteen or half an hour if you want, but usually it doesn’t take too long. Just like in the real world, not every trip to the calm place will be equally calming, but with practice it can become a way to calm yourself, sometimes in a remarkably short time. Feel welcome to create more than one safe, calm place for yourself. If you are blessed with many memories of safe, calm places that you love, feel free to take a brief tour of them over a short period of time as an alternative to the imagery process, stopping to savor the sights, smells, sounds, tactile sensations and even tastes of each.

As always, this is not a substitute, alternative, or replacement for therapy with a qualified behavioral health practitioner.

Photo by the author.

Posted in anxiety, behavioral health, Distress tolerance, Feelings | Tagged , | 3 Comments

Ignore Your Feelings

So, did that get your attention? What’s a therapist doing telling people to ignore their feelings? Aren’t we, the therapists, supposed to help people get in touch with their feelings? Not necessarily.

Portrait, Child, Hands, Hide, Hiding, Playing

This is going to be a relatively short post, and it won’t be as linked to studies, etc. as I normally like. But it came to my attention when I saw an online article titled “motivation is overrated.” Going back and doing a web search to find it, there are too many hits for me to search for the original, so I can’t link to it quickly. But the example I perused was focused on doing exercise and pointed out that lots of times you just don’t feel like doing something, even if it’s good for you. I once was facilitating a therapy group in which we got talking about what was most harmful about depression, and there was a lot of support around that depressed feeling of “I don’t wanna…” where the completion of the phrase could be anything from brushing one’s teeth to taking antidepressant medication. So I’ll cut to the chase: that’s when to ignore your feeling.

The DBT people are big on what they call “wise mind”, which is the intersection of your emotional mind and your rational mind. So when I don’t feel like doing something like getting up when the alarm goes off, but my rational mind tells me that things will be better in the long run if I go to work– especially arriving on time– that’s when I lean more heavily on my rational mind. There’s still an emotional component, but it’s relatively subdued (I know I feel better when I do the right thing) compared to the more dominant emotion (I want to sleep in!).

This skill is important when dealing with mood disorders. If I’m depressed, I frequently have to confront that feeling of “I don’t wanna.” I need to engage in simple self-care activities, get exercise, make it to appointments, etc. even when I feel like doing nothing. If I’m anxious, I may feel a strong desire to run away, as with experiencing panic symptoms in public from agoraphobia. In both cases, I’m feeling a strong negative emotion. In both cases, I can get a better long term outcome if I disregard a strong negative emotion and take action based on a more rational analysis of my situation. Is it difficult? You betcha. But life is hard, and this is one of those avoidance-avoidance choices, or as I like to say, a choice between two bads. You will choose, because the only choice we never get is to not choose, but one of them is still better than the other. That’s why sometimes you have to ignore your feelings. Later, when the fuss has died down and you get back in touch with your feelings, you’ll feel better.

Afterword:

So obviously I’m not really telling you to ignore your feelings in the sense of being in denial, or what people call stuffing feelings. For those who like a reframe, what I’m saying fits with the old saying, “Feel the fear and do it anyway.” There’s a more nuanced, more depth-oriented way of looking at this. I may have an underlying feeling, such as “I want to escape from addiction” which is temporarily crowded out by a more surface and immediate feeling of “I want to get loaded.” This means that the other way of looking at it is to take a moment and choose which feeling you want to guide your actions.

image source: https://pixabay.com/photos/portrait-child-hands-hide-hiding-317041/

Posted in anxiety, behavioral health, choices, Depression, Dialectical Behavior Therapy, Distress tolerance, Emotions, Feelings, mental health, Uncategorized | Tagged , , , , | Leave a comment

More on Mindfulness

It’s been a while. Like many Americans, I’ve been watching the news and riding the roller coaster. But something happened earlier today that brought me back to a kind of everyday mindfulness, which my Midwestern forebearers would have probably called “paying attention” or “keeping your mind on what you’re doing.” This fits in more with what many current writers have called “secular mindfulness,” something taken from Buddhism but not connected to Buddhist doctrines, dogmas, etc.

How To Finely Chop Vegetables

Let me give an example taken from the world of sports. In an American football game you may have seen a receiver go out for a pass. The ball is thrown and the receiver, who is open, gets a good toss but doesn’t hold on to it. The commentator may say, “He started to run before he was done catching it,” or something to that effect.

You may have noticed something like this in yourself or others while driving– people who speed up excessively on a surface street that leads to a freeway on ramp. Their minds are on the freeway while they’re still physically on a surface street. They are not present for the time and place they are actually inhabiting.

Let’s use a bigger example– the presidential election. Now that it’s over, you may be looking forward to (or dreading) a new president. Not living in the moment, are we? Whether the results stand (as they always have, not counting 1876, about which people can still argue) or not, it’s nothing I have any influence over– nor do you, unless you’re an expert in local election law in a handful of states. We come back to that Buddhist mantra, “…. grant me the serenity to accept the things I cannot change.” Oh, wait, that’s from a Protestant prayer.

The thing is, I do have the ability to focus on what’s in my environment with my senses right now. That could be doing a budget or taking out the trash. It could be listening to a loved one– or talking to them. When I devote some (or all) of my attention to the future or the past, there’s less of me in the present. So mindfulness isn’t necessarily a meditation practice, but can also be an everyday practice for cooking, studying, being in a relationship– anything we do. As the DBT people put it, “one thing in the moment, five senses, non-judgmentally.” I was going to write more, but it turns out that someone else beat me to it. So I encourage one and all to read the article on mindfulness as an everyday practice, and to practice mindfulness with whatever you are doing right now. My experience is that life becomes less stressful, and I become more resilient. And, as with mindfulness meditation, when I fail at it, I observe the failure non-judgmentally and turn the mind back to whatever I was focusing on.

image from https://morningfresh.com.ng/finely-chop-vegetables/

Posted in Crisis survival, dealing with change, Dialectical Behavior Therapy, Distress tolerance, mindfulness, Uncategorized | Tagged , | 1 Comment

An Inspirational Moment

I just have to share this, even though it’s far from new content and completely off topic for this blog. In a time of radical wealth inequality, there is a billionaire who has given away an eight billion dollar fortune.

At a time when not just income inequality but wealth inequality are hot topics, It’s inspirational to hear of someone who didn’t use their money to found yet another plutocratic, oligarchic dynasty. He even got some other plutocrats to promise to give away at least half of their billions. You and I will never get to do anything like this, (unless a billionaire stumbles across this blog, highly unlikely) but we can live our own values to the best of our abilities.

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It’s Not Bad to Feel Bad

I usually try to post something at least monthly, but I have fallen short of that goal. I also try to post on a topic that is not too common, or that relates to a personal interest, But no topic has seemed both personal and topical, considering what has been going on in the news– the bitterness of our politics, the continued public health crisis, social upheaval and conflict and here in California, the fires. Then I saw something that reminded me of a point which, while not unique or special to me, is highly topical: thus the title of this post. I saw an article about how prevalent mental health and addiction symptoms have been during the pandemic and there were no surprises. But one piece of the puzzle is something I have written about before– don’t chase your tail emotionally speaking by feeling bad about feeling bad. Don’t judge your negative emotions negatively.

My local public broadcasting station ran a good call in/talk to the experts segment on coping with all these things at once, and also summarized in an article. The podcast of the initial show is also available.

The key points that resonated with me included self-care; recognizing that I need to take care of myself for a great many reasons, including being able to be there for others if possible but also seeing myself as being equally valid as a recipient of nurture along with others, and framing this in self-compassion: talk to myself the way I would talk to my best friends if they were going through the same thing. The thing that hit me, resulting in this post, is the basic truth: you are not alone. We are all going through various levels of stress. Even those who are relatively unscathed may be experiencing guilt over being better off than others or frustration over normal channels for being able to help others not being available.

Another of the things that came up was that we are, indeed, living through an unprecedented set of conditions. Nobody has gone through this experience. In that sense, we are all on an equal footing. At the same time we need to recognize that our nation has gone through other extremely stressful times– a great civil war, fought on our own soil. A crushing economic depression. Other episodes of epidemic or pandemic illness. Political crises and civil unrest. And we have gotten through these as a country and our parents, grandparents, and great grandparents got through them.

One thing that I’m surprised no one has brought up– limit the amount of time you spend with the news. It’s stuff you can’t change. If you want to be a political activist you can phone bank or do other activities, but you don’t need to scroll through a dozen news stories that show a dozen different views of the same stressors. It’s OK to look for the “aw” stories about the dog that pulled the child from the burning building or how a couple got married in their 90’s or anything that gives you a boost. Avoid triggering your trauma by visuals of bad things that have happened. It’s OK to give that a pass for today. Recognize that you are going through grief and loss, among other things.

Take care of yourself; be willing to both ask for and to give support. Talk kindly to yourself in moments alone. How would you support your best friend?

photos copyright James Matter 2020

Posted in behavioral health, Crisis survival, Distress tolerance, mental health, Trauma | 2 Comments

Your Forgiveness is for You

forgiveness lovely quotes

I have not been posting very often because I continue to try to keep my original purpose of writing about things I haven’t seen mentioned elsewhere, but this piece was just too good to not pass along: it’s about forgiveness.

The author makes a couple of points that I just want to highlight. The main one is the title of this post, which is that when we forgive, it’s because having forgiveness in my heart is more healing for me than having feelings of anger, resentment, and fantasies of revenge. The classic line from 12-step folklore is, “It’s like taking poison and hoping the other person dies.” When we undertake the process of forgiving, it’s not about the other person, it’s about peace in our own hearts. The other thing is the danger of unforgiven material turning into resentment. Again, the 12-step world has processes for dealing with resentment, and this is the only place I’ve seen where there is any material on dealing with resentment.

The third thing that I think is important is the tip from the article that this may not be something you can do without a therapist. I have had professional experience with people who were survivors of some very traumatic abuse who wanted to engage in a process of forgiveness for a perpetrator, but this can be extremely tricky. The article talks about feeling your feelings, including anger. It also may involve remembering trauma. Not necessarily work to be done alone.

At this point I want to take a short digression into anger management. Many years ago, I was taking anger management group facilitator training and the trainer asserted that anger is never a primary emotion. Not only that, but it is always a stand in– a front, if you will– for either anger or sorrow. I easily accepted the idea that anger is not a primary emotion, but questioned that the only underlying emotions are fear or sorrow. I’ve been thinking about it for twenty years and have never identified a third source for anger. The thing is, anger is essentially a defensive emotion. We’re talking about fight/flight/freeze responses to threat, here. Fear and sorrow are vulnerable emotions, while anger– or even rage– is protective. If I’m on the attack, I’m doing something about my fear or sorrow, although it may be the wrong thing. I can get away from feeling those painful emotions, even if only temporarily. Anger is defensive in the classic sense of the saying that the best defense is a good offense.

The piece points out that forgiveness is a process with steps, and my experience is that it is the final step in a larger process of dealing with being a survivor of trauma. The best process for dealing with trauma that I know about is the Seeking Safety curriculum, which starts and ends, for the most part, in helping trauma survivors deal with the negative emotions that have to be experienced when healing from PTSD. So the process of forgiveness as mentioned in the article may be about forgiveness for something that is emotionally problematic but does not rise to this level, or it could be for something much more troubling. Premature and unaided attempts to engage in forgiveness for perpetrators of serious trauma may be damaging. As they say in some infomercials, “…do not attempt this at home.” If you embark on the process and it is too disturbing, there may be other things you need to do first. Don’t be hesitant to enlist a trained professional. Good luck.

And a small afterword: When we consider how difficult it is for ourselves to forgive others, we are well advised to go softly and refrain, wherever possible, from doing things that may require people to forgive us.

image source: https://sayingimages.com/quotes-about-forgiveness/

A short note about the image

Do a web search for images around the word forgiveness and you will see a great many images, but they will all have words, or at least the first several pages I looked at did. Sources include a great many quotes from Christianity as you might expect, but also from other world religions. I chose the one from C. S. Lewis not because he’s a Christian, but because I thought it was funny, and reflected that forgiveness is far from easy.

Posted in Anger, arguing, betrayal, communication, Couples and relationships, Feelings, Uncategorized | Tagged | Leave a comment

Restraint, Asking for Help

I recently saw a post on social media representing nurses and pertaining to our newly-reinvigorated struggles for equality. “Friendly reminder that nurses have to restrain violent, confused, intoxicated and belligerent people all the time. And we make it happen without crushing anyone’s windpipe.”

It reminded me that I once worked in a setting where the staff were occasionally confronted with assaultive clients. Everyone was trained on how to restrain them if it came down to it, but most of the training was on how to de-escalate them. We were specifically trained that, due to the clients being in a residential treatment environment and being minors, under no circumstances could we do anything that might be construed as assault by us against them. In fact, the training included a lot on how to run away, how to escape, to be aware that destruction of property was OK as long as there was no danger to other people. Nobody was armed and the furniture was mostly too heavy to pick up so there were no weapons involved.

The quote referenced above brought back a few memories, but also brought me back to some of the recent discussions about the topic that depending on your sources and your political bent, may have been labeled “defunding the police” or “re-imagining policing.” Some police departments have already announced that they will no longer send armed officers to calls about homeless people or other issues that are not clearly and immediately public safety threats. Fine, but who will they send? Some jurisdictions have what are called “PERT” teams, an acronym for Psychiatric Emergency Response Teams. I always flinch at names like this because I hate it when people say “ATM machine” when the the M stands for machine, or “PIN number” when the the N stands for number, but that’s just one of my little issues… Where were we?

The thing is, a licensed mental health practitioner takes some time to train, and then crisis intervention training is a specialized sub-field. But it definitely takes longer than most police training, which can run perhaps six months. To the best of my knowledge, and I have not done deep research on this, you go on the payroll when you enter the police academy. When I was training to become a Marriage and Family Therapist, there were no public health departments anywhere that offered to pay for two years of training and 3,000 hours of supervised experience in return for accepting a government job as a mental health professional.

Hmmm… there’s a thought. If we want to take money that has been used to militarize policing and use it to humanize policing, this would be a clear path to address a clear need for street-based mental health crisis intervention. If we really want to re-imagine the police, or divert money from urban assault vehicles to mental health responses, maybe we should look at training and funding this kind of service. Do a quick web search for “Tactical Armored Vehicle” and see all the vendors. Look at a few pictures. How much do you think one of those babies will cost? How many trained mental health professionals could we add for the cost of a couple of those? And the mental health professionals would be working full time, every day, not sitting in a garage waiting for civil unrest to break out. Maybe if we did that, we wouldn’t be so worried about civil unrest.

I’m not going link to a bunch of sources here. I encourage everyone to do homework. I remember going to a conference where one presenter showed a chart that documented a change that happened during “de-institutionalization” of California’s severely mentally ill. In one Bay Area county, the year that a large state hospital closed, the county jail population doubled. So “de-institutionalization” was a de facto criminalization of mental illness. Today, the three largest locked ward mental hospitals in America are all county jails. This is in addition to the mass incarceration resulting from the war on drugs famously started by Ronald Reagan and carried on by most of his successors in the White House. Again, I didn’t personally check the numbers but the head of a Bay Area behavioral health department said publicly a few years ago that funding for addiction treatment has been flat for forty years.

Changes take time and money and political will. Most communities, whatever they say, are not going to disband the police force in the next couple of weeks. But we can and must train the existing cops more rigorously in de-escalating upset people. I recently saw a video of a cop pulling a gun on a guy who was unarmed and not assaultive. The citizen was being uncooperative, most certainly qualified as resisting arrest. But the law enforcement guy totally lost it and threatened the citizen with what amounts to summary execution. That’s not right in anyone’s book. Notice I have scrubbed all references to race. Feel welcome to look up statistics on which category of unarmed jerks resisting arrest get shot the most (no surprises) but even one person, of any race, is too many. De-escalating situations is the most needed skill, and I’m just going to guess, not the most widely trained and probably not reviewed. There is an established curriculum called CIT, Crisis Intervention Training, so we don’t need to invent it. We need to train everyone in law enforcement to do it.

So my modest proposal is this: train, train, train the existing officers on restraint– restraining themselves, de-escalation, and how to restrain people without damaging them if it comes to that. In the video referenced above, two cops ultimately restrained and arrested the citizen. What I don’t get is, if the cop in the first part of the video knew he had backup and the citizen was unarmed, why did he even draw his weapon? It leads me to speculate that the officer himself was on edge and ready to snap. That brings me to my second proposal, perhaps a controversial one: take better care of the cops. I mentioned this briefly in the last post: we know that these men and women are in a high-stress job, get exposed to a lot of trauma, have a high suicide rate, and have a culture which discourages asking for help. But we can change that. If, for example, all officers had a monthly meeting with a mental health counselor it would eliminate the stigma of talking to one. Would they resist it? I imagine so. Providing mental health assistance might be more controversial with the cops than the general public.

People tend to resist change. If there were more PERT members available with the ability to do rapid response in the field 24/7 then the cops could call for them. If the cops all had CIT they would be more confident about their own abilities to de-escalate situations. All this costs money, but so do those armored vehicles. So does incarceration of the mentally ill. So do lawsuits that arise from shooting unarmed mentally ill citizens.

If we re-imagine policing as a high stress job which seriously damages the mental health of its practitioners, then we can start to reshape to stoic culture of “the thin blue line.” Is that a long term culture change project? Absolutely. But then again, so is fighting systemic racism, and most people are up for that. If we want to rehumanize our society, we need to destigmatize homelessness, poverty, being female, addiction, mental illness, being Black or Brown, LGBTQ–and being a cop. Check your reaction to the laundry list. If you were nodding your head right up until the last item…

Re-imagining policing does involve de-funding: de-fund the war on drugs. De-fund the militarization of the police. But not generically de-funding government. We have been on that path for forty years and it has led us to this. Spend the money on helping both the people on the street and those who respond to them. Rehumanize our society. It’s cheaper in the long run, and ethically far superior.

We all need to keep looking at ourselves, working on our own prejudices. I’m with you on that. I’m still working on my own, and I hope I will keep working. Stay safe. Help others to stay safe. We’re in it together. Remember what the Buddha said– “Hate never conquered hate.”

(Sadly enough, the top image comes from an eight year old article about defunding mental health clinics in Chicago, where Cook County Jail is one of the three largest inpatient mental health facilities in the nationhttps://www.huffpost.com/entry/chicago-mental-health-clinic-closures_b_1333498?slideshow=true#gallery/5be1f911e4b0aeaf24c47f18/5)

end photo by the author copyright 2020

Posted in behavioral health, change, Crisis survival, mental health, stigma of addiction, stigma of mental illness, Trauma, Uncategorized, Violence | Tagged , , , | 2 Comments