Pay Attention When I’m Talking to Me!

little girl talking to herself in the mirror

Just want to follow up on the last post, because I met with a client earlier a couple of weeks ago who specifically wanted to start working in a cognitive way. The hardest part of doing cognitive therapy, I’ve found, is to start. This makes doing cognitive therapy a lot like everything else, of course, but I’ll forego a juicy opportunity for digression.

The thing is, when we think, we are talking to ourselves. Thinking is not an automatic pronouncement of absolute truth, a description of absolute reality, or anything else. It might be a pronouncement of absolute truth, a description of absolute reality– but most likely not. What it usually is, is an inner monologue. Sometimes, it’s true, we may think in music, or think in images, but mostly we are talking to ourselves, either consciously and deliberately or not.

Cognitive therapy involves looking at this inner monologue and challenging the cognitive distortions. So if I’m feeling depressed over a failed relationship I might tell myself, “All my relationships fail. I’ll never have a successful relationship.” One cognitive distortion there is fortune telling. Another one is all/nothing thinking. In this case, the two overlap. Even the assertion that “All my relationships fail” may be suspect– perhaps if I review my relationship history I’ll realize I have sometimes dumped other people, or we called it off mutually. Even if I determine that I was dumped every time, I will likely have to admit that the relationships worked for a while. In short, the statement was not a statement of absolute truth, it was a judgment call– and I may have slanted the judgment against myself!

But the hardest part for so many people is to recognize that what I’m looking at here is my own inner monologue, not a statement of objective truth or reality.  The best statement I ever heard about this process came, as so many pearls of wisdom have, from a client. She said, “When I’m talking to myself, paying attention is a form of self-respect.” Listening carefully to the inner monologue and recognizing it as my own voice, talking to me, is a sometimes difficult but invaluable step in being able to change.

Image source: https://www.mnn.com/health/fitness-well-being/stories/go-ahead-talk-yourself-its-good-you

Note: the image source also includes a post about the practice of deliberately talking to oneself and why it helps. Here I’m writing about something significantly different, the process of being mindful of one’s own inner monologue, which seems (and may be) spontaneous and unguided, and the recognition that it comes from me.

 

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Power Tool Safety

Hardware Power Tool, Vector Files

A theme that I come back to again and again in my work with clients is that one’s mind is powerful. My joke about that is that you need to use such a powerful tool safely. Another thing to keep in mind– and we learn this from mindfulness practice–is that you are always thinking. You may be thinking about what you want for lunch, or you may be thinking about the kid that bullied you in second grade, or you may be thinking about a revolutionary way to deliver behavioral health care. It’s all thinking. Additionally, you may be flooded with emotions of various kinds, be hearing mental music, or other kinds of mental processes may be going on, but whatever is happening, the mind is always on.

One of the most salient examples of how we think– again, one that comes up repeatedly– is how “should” statements work. When I first started studying cognitive therapy, this one baffled me, I’ll admit. Isn’t it true that people sometimes should behave in certain ways? Isn’t it true that we should be polite, be considerate of others, be responsible for ourselves, and a long list of other shoulds?

Albert Ellis, who famously originated REBT, used to tell people, “You’re shoulding all over yourself!” When I first began to understand the problem with should statements, I realized that they are comparisons.  The world is one way, and we want it to be another. I used to tell people that when they used should statements, they were at war with reality, and reality would always win. That seemed harsh to me, and I looked for a different way of putting it. One day I came up with an alternate frame. I told my client, “Every time you say ‘should’ you just created a parallel universe where things went differently.” This is in keeping with my view that each of us has a very powerful creative mind. Our minds are so powerful that we can, with a single word, create a parallel universe where things went differently. It also takes the harsh, judgmental edge off of spotting our shoulds. It’s OK to wish for something different; we just want to recognize that we don’t have it.

From whatever trick of language, however, the should always comes out as a kind of accusation: you should be better– but you’re not. You are, in fact, bad, and in addition to being bad, you’re shoulding all over yourself.  Dang, Dr. Ellis! I already feel bad– that’s why I’m in therapy! Can’t you be a little nicer? Well, any therapist will tell you that sometimes you have to give people bad news, and sometimes you have to be blunt.  But the flip side of that is the well known saying that diplomacy consists of telling someone where to go so nicely that they look forward to the trip.

To me, that’s the whole thing about having the  power to create a parallel universe where things turned out differently– with a single word. So to come back to my original puzzlement with the problem with should, there’s absolutely nothing wrong with visualizing a world where people are polite, are considerate of others, are responsible for themselves, and so on. It’s just that it’s a goal statement. Of course people want a world where people are polite, considerate of others., and so on. To crib yet another trite and true statement, for your dreams to come true, you must first dream. But the problem arises when you forget that it’s a goal, not a reality. “I should be more assertive.” “I shouldn’t be so depressed, anxious, obsessive…” Language is such a weird tool, isn’t it? Try saying it this way: “I want to be more assertive.”  “I want to feel more relaxed, more positive…” Now it’s a goal statement, not an accusation.  Now I’m using that power tool– my mind– in a safer, dare I say it– saner– way. I’m trying to get to a better place, not condemning myself for not already being there. And taking credit, as well as responsibility, for being a powerful, creative person.

Image source: http://clipart-library.com/clipart/76963.htm

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The Life You Save May Be Your Own

My apologies to those who have been waiting. Someone who I see personally reminded me that I hadn’t posted anything for quite some time, and I reiterated that I first started this with the avowed intention of creating only original material, but a busy schedule is the enemy of reflection, and I have been busy.

The topic that I’m thinking of right now is hardly original– suicide, and the prevention of suicide. The intention to write more about it was galvanized into action by reading an item on the NPR website about cutting suicide risk after a hospitalization for an attempt. One of the key points in the story is that suicidal thoughts, feelings, and urges don’t last very long– anything from a few minutes to a few hours. For those who have followed this blog, you may remember my post about how the negative mood time dilation effect can make an hour seem like forever. Still, it’s endurable, and survivable. Some of the ways to get through this crisis time are skills such as those taught in DBT; self-soothing, distraction, and turning the mind.

The story also points out that what has worked is creating a safety plan with the help of a trained professional. I have done the safety plans  with a number of people who were in crisis, and all of them are alive today.  If you are thinking of doing the safety plan on your own without use of a professional, my suggestion is to contact a professional mental health person as soon as possible, but if you feel an urgent need to create a safety plan for yourself, then go ahead– but get the professional help.

The other thing that I have written about before which relates to this is the truth that we can be experiencing very strong negative emotions– grief being chief among them– without having a mental disorder. We can also, alas, have strong grief and other negative emotions concurrently with a mental disorder. Life doesn’t allow us to put one problem on hold while dealing with another, unfortunately. My image for this has always been that the ship of my life is at sea with a leak in the hull and a fire on deck. If I only fight the fire, the ship sinks. If I only fix the leak, the ship burns to the waterline. Sometimes there’s no getting around it. But experience shows that when we get through the crisis, life can have good things for us again on the other side– or even in the middle of the crisis.

When I think of this topic I remember a client I had who shot himself in the head– before I ever met him. By some miracle, no part of his brain was definitively damaged, and he recovered. By the time I met him, he was seeking help for other problems, and was no longer suicidal. In fact, after his attempt, he had endured trials that would have made other people become suicidal, but was not. Sometimes the light at the end of the tunnel really is daylight.

 

(image from https://www.rd.com/culture/rainbow-facts/)

Posted in behavioral health, Depression, Distress tolerance, Emotions, Grief, mental health, suicide, Suicide prevention | Tagged | Leave a comment

May Is Mental Health Awareness Month

Just wanted to give that shout out to Mental Health Awareness Month before it’s over. Before looking it up, I didn’t know that it has been going on in one form or another since 1949

.Image result for mental health month 2018 images

This year the theme is #4mind4body and there are various things about mind/body wellness that you can find at the link.  Here’s just one item from the toolkit:

Health and wellness are hot topics, but did you know a healthy lifestyle can help to prevent the onset or worsening of depression, anxiety and other mental health conditions, as well as heart disease, diabetes, obesity and other chronic health problems? It can also help people recover from these conditions. Learn about the mind-body connection with this year’s #MHM2018 fact sheets: bit.ly/MayMH

There’s also some interesting stuff about new developments in gut health and mental health. As a part-time tree-hugger, I like the idea that every person is a walking ecosystem and that care of our personal gut ecosystem can make us feel psychologically better.

For me, the great advantage to doing the physical health side of mind/body wellness has always been the concrete, tangible nature of it. If I go for a walk or eat a healthy food, I know I did it. I know I can do it again. It’s real & nobody can take that away from me.  That, in itself, creates a mental boost.

Take care of yourself, and reach out to each other. This month, and every month.

image from http://www.star-center.org/mental-health-awareness-month/

 

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Anger…

…is not necessarily bad. The two best things I try to remember about anger come from the Seeking Safety book and from a training I attended some years ago on facilitating anger management groups (which tend to be mostly mandated clients with criminal justice involvement).

The first idea, from Seeking Safety, is the idea that anger is a sign of unmet needs. That makes complete sense to me. If there is something I need, and I’m not getting it, I can get angry.

DSCN1620The second idea, from anger management, is that anger is not a primary emotion. It is, in this view, a secondary emotion, a front for either underlying sorrow or fear. In fact, the trainer who taught the course went so far as to say that anger is never the primary emotion, and that it always is a front for sorrow or fear. Such a categorical statement piqued my interest, and especially my sense of contrariness. Is there never an exception? This was many years ago, and I’m still looking for an exception.

Here’s the basic idea about why we get angry: fear and sorrow are vulnerable emotions. Anger, and especially rage, represent a strong, even an invulnerable feeling. The ultimate version is when someone goes berserk or runs amok– two words, one from the Vikings and one from Malaysia, that represent what some translators have called “battle fury,” the extreme fight-or-flight reaction where strength greatly increases, sensitivity to pain may be greatly diminished or absent, and rational thought is on hold.  When a person gets addicted to being high on their own fight/flight chemistry, this person is the classic “rageaholic.”

From some perspectives, we can see the up side of anger– if I’m truly in a life threatening situation, going berserk has survival value. We have heard the stories of the mom who lifts up a car when a jack slips, pinning her teenage son, and pulls him to safety, or the wounded soldier who runs fifty yards to safety after losing a foot. There are various true examples of how this extreme physical reaction can be life-saving. What the stories don’t include is that the mom has a bad back forever after & the wounded soldier is still in very bad shape. But lives have been saved.

But most of us are not in life or death situations when we get angry. So what’s the up side then? Well, feeling strong, feeling less vulnerable. If you hurt me and I get angry with you– even fly into a rage– now I feel strong, not vulnerable. So which do I want to feel? Strong and invulnerable, or hurt and vulnerable? It’s understandable, seen in this light, how one might choose the strong, angry feeling over the vulnerable, sad or fearful feeling.

The problem with choosing the invulnerable anger response is that when it borders on or becomes rage, rational thought is typically shut down. Perhaps I can’t stop to think that my spouse obviously didn’t mean to get in a car wreck– I just focus on the fact that the car got wrecked and my spouse was driving. I may not even stop to think if it was the other driver’s fault, or if I do my rage might be dangerously directed to that person. The anger management people suggest that when the fight-or-flight chemicals dump into my system, it will take at least half an hour for them to wash out.

Here’s where I double back, to the Seeking Safety idea that my anger is the sign of an unmet need. If I’m angry about the damage to my car, it may be due to my sudden fear that my loved one might have been injured or killed, or worries about money, or any number of perfectly valid fears. But none of those needs can be addressed with a baseball bat or shouting. If need be, I take half an hour to calm down before talking to anyone– especially the person I’m upset with. It’s always interesting to me that some people have intuitively figured out that they need to take a walk, or sit in a quiet room, or otherwise calm down before continuing to deal with an upsetting situation. It’s equally interesting (puzzling, I’ll admit) that people can get coaching on this, including the physiological reason for why it’s necessary, and still not give it a try.

The other thing about anger is that anger is a form of energy. We can think of emotions as our motivators– the driving forces of our lives. So it’s good to have energy, but it needs to be usefully directed. The rational mind is the part that channels the energy. Practically speaking, it’s better to self-monitor and respond to unmet needs (anger) when they are still manageable. This is the part where the client-therapist dialogue, or an inner dialogue with oneself, begins. How do you stay aware of your own needs, your sorrows, your fears, your anger? How do you monitor yourself? What ways do you have to meet your needs? If you feel you have an anger problem, you need to be able to answer those questions in order to successfully cope with anger and without negative outcomes. Anger management is an entire industry, but enough for now.

 

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Grief and Depression…

P1010116 (2)

Are not the same. I remember a client once saying that she had broken up a longstanding relationship and her parents were worried about her becoming depressed. She was, in fact, on antidepressant medication and had been having problems. However in this case, she told them, “I’m not depressed, I’m sad.” It makes sense, doesn’t it? On the other hand, just because you’re sad doesn’t mean you’re not depressed, and vice versa.

In one of the first professional trainings that I attended as a peer counselor, the psychiatrist who was presenting on the subject of co-occurring substance use disorders and other mental disorders repeated several times, “Just because you have one problem doesn’t mean you don’t have another.” This applies just as much to the combination of grief and depression.  It is potentially even more applicable because of the existence of complicated grief. A great discussion of all these  can be found here.

For me, one of the key points is that grief is not typically associated with feeling like a personally flawed or failed person. Depression, however, often includes such feelings. When I grieve the loss of a loved one, one of the things that I am aware of is that the person had endearing characteristics which I recall fondly, albeit with grief for the loss. Depression rarely includes such positives. Likewise, in grief I am aware that my period of grieving is a tunnel which can have an end, whereas depression is more likely to feel endless.

One of the most memorable things from my training as a therapist was a statement about grief made by a seventy year old professor in a class about what normal humanity looks like. As an older student, I had already experienced some of the normal grief and loss of life, including my grandparents and many  friends in the AIDS epidemic. Some of the younger students apparently had not, and one asked the professor, “When you lose a family member, how long does it take to get over it?” The professor answered in a heartbeat: “You don’t get over it, you get used to it.” This is a key thing about grief: we never wish to forget about the loss of a loved one, and the sadness of that loss will always be with us. But we become, in the course of normal grief, reconciled to the loss. In complicated grief, we are having difficulty, sometimes extreme difficulty, in becoming reconciled to the loss. The sadness of it overwhelms the ability to recall fondly the good things about the lost loved one. In depression, there is no positive aspect, no way of becoming reconciled with the suffering, and typically no rational reason for the suffering.

In the article for which I included a link earlier, the idea of “proper sorrows” is included. Life will always bring us sorrow and loss. For some of us, it may bring depression, either separately or together with losses. For some, sorrow and loss can segue into depression. Complications like this are some of the reasons why consultation with a therapist may be a good idea. At the same time, it behooves therapists to be very alert that we do not label normal problems of life as mental disorders.

DSCN1614 (2)

Top image: Owens Valley from the approach to Shepherd Pass

Bottom image: Pacific coast looking north near San Gregorio

Posted in Depression, Emotions, Feelings, Grief, Sadness, Uncategorized | Leave a comment

Therapists Are Not Thought Police

After yet another school shooting, some conservatives  are calling for better mental health care. What they really mean is that mental health providers should be on the lookout for potential shooters & should then intervene to prevent them.

Consider this statement by the Public Defender of Broward County:

Howard Finkelstein, the chief public defender in Broward County, said in an interview that Mr. Cruz’s legal team had not yet decided whether to mount an insanity defense. Prosecutors have not said whether they will seek the death penalty, but Mr. Finkelstein argued that Mr. Cruz should not be a candidate for execution, given his mental health history.

“Every red flag was there and nobody did anything,” Mr. Finkelstein said. “When we let one of our children fall off grid, when they are screaming for help in every way, do we have the right to kill them when we could have stopped it?”

Of course people with mental illness should have access to care! It is a tragedy and a travesty that the criminal justice system should be the gateway to mental health for so many. It’s tragic that Nikolas Cruz should have had the record of problems and troubles he had, but received little or no help. At the same time, however, it is completely unreasonable to expect that mental health providers should be the ones charged with ensuring public safety.

There are a lot of problems with this. The first one is exemplified in the story of a Sacramento area woman who experienced involuntary detention for ten hours even after saying she had no intention to harm herself or anyone else. This was under the existing system in California, which permits certain people in health care and law enforcement to send people to a mental hospital for up to 72 hours against their will (5150). In fact, even when someone isn’t held for three days, the system may take hours to determine that the person doesn’t need to be held.

Patients with psychiatric disabilities took to Cape Town's streets to protest for better health care. Pic by Yazeed Kamaldien

Another problem with this is that, at least in California, mental health professionals are already required to intervene under what is known as  the Tarasoff rule. The Wikipedia article gives the long version, but the short version is that therapists are required to notify authorities if someone makes a credible threat against an identifiable target. But who makes people seek out mental health care?

Well, in California there’s Laura’s Law, which can compel people to engage in mental health treatment, but for someone to qualify a local jurisdiction has to opt in, and then a person needs to have a history of either legal problems or mental health hospitalizations. In the most recent school shooting (and most of the others) the perpetrators would not have qualified.

But it gets worse. In the 2012 Aurora Colorado shooting, the perpetrator was under the care of a psychiatrist prior to the shooting, but apparently neglected to tell the psychiatrist what he was planning. To steal one of Joker’s lines from an old Batman comic, “I may be insane, but I’m not crazy!” People who have mental illnesses are at least as complex and intelligent as people who do not.  They may suffer greatly, but have no urge to do anything violent– to others, or to themselves. We need to remember that gun suicides are almost double gun homicides. So mental health providers are already mandated by law to be on the lookout for violence risks, and to report them.  Patients know that, and can easily choose to not disclose. I personally experienced this when a client who had declined to engage in talk therapy after being referred by his psychiatrist, who was prescribing anti-depressant medication, committed a suicide that was clearly well thought out. It’s not a good feeling for a therapist.

Laws about mental health treatment, who should get it even when they don’t want it, and what mental health providers should report, when, and to whom seem unlikely to have any effect on preventing violence by mentally ill people. Even when someone is getting treatment and on the radar, the ability to predict who really is a risk for violence doesn’t really exist, beyond the obvious fact that people who already have a history of violence are likely to go on being violent.  And then there are those pesky civil rights. You can’t lock people up for Orwellian thoughtcrime. At least not yet.

But wait– it gets worse. Or at least more complicated. I wasn’t able to quickly find a reference, but there was a story about inmates in California prisons who were on suicide watch lying about their suicidality in order to be released from suicide watch– who then killed themselves. This is perhaps different from assessing threats of violence to others, or perhaps not. My experience with mental health clients who were picked up and taken to psychiatric emergency as either a danger to self or danger to others is that when they are picked up by law enforcement, many of them calm down by the time they are transported to the hospital and are not admitted. Others are admitted, perhaps overnight, and then released. The point is, people can be mentally ill, can be very upset, but then can put on a good enough front to “pass” with the people charged with holding them, even if still very ill.

One of the things that makes people more likely to disclose socially unacceptable thoughts, feelings, and impulses to a therapist is the promise of confidentiality.  Chop giant holes in the confidentiality contract between therapist and client and all you do is guarantee the clients won’t disclose such thoughts, feelings, and most important– urges. In fact, one researcher estimates that Duty to Warn laws actually increase homicides. I am not mathematically sophisticated enough to argue with the analysis, but the premise is intuitively acceptable: if a patient is planning something that the therapist would stop, don’t tell the therapist.

 

Tarasoff reporting and other laws already create the obligation for mental health providers to look out for public safety. It would also be great if mental health care really was on a parity with other forms of health care. It would be nice, come to that, if health care of all kinds was more available to more people.  But making therapists into thought police won’t help the school shooting problem.

mental health image from https://yazkam.wordpress.com/2013/07/11/mental-health-patients-protest-for-better-services/

AR-15 image from http://www.thetruthaboutguns.com/2017/02/foghorn/best-3-entry-level-ar-15-rifles/

 

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