Grief and Depression…

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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.

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Top image: Owens Valley from the approach to Shepherd Pass

Bottom image: Pacific coast looking north near San Gregorio

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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

AR-15 image from


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Three Ways to Change

Young lady or old woman illusion
(Apologies to readers for the quick updates– it’s very hard to proofread one’s own work, and I spotted a couple of typos. Probably didn’t spot some others.)

I have reflected on many occasions that the therapist’s job has a lot to do with helping people change. But how can a therapist promote change? I think that there are three main ways.

First– and that’s why the picture– we can change by changing how we look at things. The picture will be familiar to a lot of people as an example of two things– a young woman looking away from the viewer, showing her left ear and cheek, and an old woman looking toward the viewer’s left, with what was the young woman’s smaller chin as the older woman’s larger nose. Helping people to see things differently is sometimes called reframing in the therapy business. I like to joke that politicians are evil spin doctors, while therapists are benevolent reframers. It is true that seeing things differently can change how you feel about a situation & your prospects for the changes you want. But reframing is a hazardous undertaking: a well-meaning friend once told me, when I mentioned being down about a romantic break up, “That’s great! you got the wrong relationship out of your life to make room for the right one!” The friend was actually right, but it was the wrong time & the wrong way to say it.

One of my personal Hall of Fame reframes came spontaneously from a client who was talking about dealing with some truly horrendous life difficulties. In a tone of frustrated disgust the person said, “I wish I wasn’t so good at this!” It sums up how we so often feel about getting through life’s vicissitudes. I’m getting through, and I’m good at dealing with my situation, but I wish I didn’t have to be!

The second way of changing is the method sometimes characterized as “Act as if” or “Fake it ’til you make it.”  This is the behavioral method. You ask yourself, or make a plan together with your therapist, about what your outward actions would be if you didn’t have your problem. Sometimes, when making a treatment plan with a client, I ask “What would success look like if we had video of you living your life successfully, but with no sound?” This is very appropriate for things like agoraphobia. If I’m unable to get out of the house, success looks like me being out of the house. In fact, behaviorally oriented treatment for phobias in general is one of the most successful forms of psychotherapy.

The key is to remember the behaviorist’s maxim, positive reinforcement for successive approximations of the desired behavior.  If I have agoraphobia and experience panic from going out the front door, I won’t start my “act as if” change with a cross-country road trip. I will more likely start by going out the back door and standing right next to it for a minute, then maybe going ten feet into the back yard for two minutes, and so on. I actually did this with a client at one point with good results.

There are more complicated examples of the “Act as if” behavior change method, but the basic idea is that change works from the outside in when using this method. The thing that makes a therapist necessary a lot of the time is the therapist can provide feedback about what constitutes a next approximation of the desired behavior as well  providing the positive reinforcement. Coping with phobias in this way frequently entails a degree of distress tolerance, which is another topic all by itself. A client may be highly self-critical about progress where the therapist can, in a wholly dispassionate way, point out that the client is, in fact, making progress. Which brings us to the third way to change.

The third way to change (for our consideration right now) is how you think about things. This includes everything that comes under the heading of cognitive therapy. Much of what we consider thinking is essentially talking to ourselves– with our without moving lips or making noise. Some might consider this to have a high degree of overlap with the first kind of change, how you look at things, and I won’t disagree, but I think the two are different enough that this is a distinct category. To illustrate the overlap, I like to think of the example of the half full glass– or is it half empty? How we label it verbally is one thing, and how we actually see it is related. But I like to say that to a person drowning, the glass is half full– of air. Or to the efficiency expert, it’s twice as big as it needs to be.  To a more inquiring mind, the question might arise, half full of exactly what liquid? Maybe we have assumed it’s water when it is, in fact, glycerin, another clear liquid. So how we think about things does overlap with how we see them.

But how we think about things includes, most importantly to my way of thinking, the way we think about things not seen.  So to return to our hypothetical agoraphobia case. Maybe the person has trouble going out because of a fear that the neighbor will be looking out the window and holding a grenade launcher, ready to attack. This may be a firmly held (false) belief– a delusion. Working with delusions and hallucinations is outside the scope of what I’m talking about for now. But the person who is in fear may recognize that the fear of the heavily armed neighbor is irrational and highly unlikely, but still have the fear. It’s possible to change this by fact-checking oneself. One could, for example, call up the neighbor and ask, do you own a grenade launcher? The example is deliberately silly, but the basic idea remains. A closer look at many forms of anxiety suggest that we are making up a story about the future– an overly worried story. A person with social anxiety is making up a story in which he or she is the focus of disapproval by all the people in a public place.  Panic disorder may arise from having fear of the consequences of a panic attack in an inconvenient place/time– even when an objective examination of a person’s history may show that panic attacks, while extremely unpleasant, haven’t stopped the sufferer from getting through life.  In this case, the story one tells oneself about the attacks can create more problems than the attacks themselves.

Different therapist have labeled this process differently in the past. Albert Ellis combated irrational beliefs in  his Rational Emotive  Behavior Therapy, And Aaron Beck it is the name most associated with CBT, cognitive behavior therapy, which helps people identify cognitive distortions and combat them. I have a point of  difference with these approaches in that I feel they put up a significant barrier to change. If I am a client and a therapist tells me my thinking is irrational or distorted, that doesn’t help me feel much better.  I know I’ve got problems, which is why I’m in therapy. Don’t tell me I’m bad when I already feel bad! (For more, see Beck or for a more reader-friendly version, Burns.) Believing one is worthless because of feeling worthless in an example of the cognitive distortion known as emotional reasoning.

So how do we use these tools without the tools themselves hurting? Here’s my proposed approach: we see ourselves as creative story tellers. Let me explain. A person takes something from real life– a painful failure, for example. I’m attracted to someone and hope that they may be attracted to me, so I ask them out.They decline my offer. I feel hurt and disappointed. Now I make up a story, and it goes like this: “I always get rejected, I’ll never have a lover.” It’s a short story, and a tragic one. But it’s made up. When I start fact-checking myself, things may be different. Maybe I had a lover in the past, which proves that my statement about never having a lover is false. Likewise, if I had a past relationship it demonstrates that the word always is too extreme. This is a way of identifying the thinking problem that is labeled “all-or-nothing” or “black and white” thinking. I still may have relationship problems. Maybe I pick inappropriate candidates as potential partners. Maybe my relationship failed because of something I did, or through no fault of my own– the other person might have their failures & shortcomings, too. But all/nothing doesn’t help me identify a path to success.

So here’s my reframe of CBT itself: we are all creative story tellers, even myth makers. It comes to us so naturally that we don’t even realize we are doing it. We make up stories and we fall in love with our stories. We even come to believe our stories. But sometimes our stories aren’t helpful; they can even be hurtful. We can mitigate the negative effects by fact-checking our own stories as dispassionate journalists, or scientific researchers might.

In the example above, there is still the pain of rejection by the hoped-for partner. This process doesn’t solve all problems, it’s just a tool. Solving problems requires other things– patience, practice, careful observation, diligence. But it is a great place to start.

For example, I just used the word partner in the rejection example. That suggests that I already made up a story about asking someone out, them accepting, us getting along, getting along even better, my attraction being reciprocated, and a relationship developing. Stories pervade our lives so deeply that it takes thoughtfulness to spot them, and a single word can reveal a rather detailed story.

The point that I want to emphasize is that there’s nothing inherently wrong or bad about the story. Another example– the famous statement, “For your dreams to come true, first you must dream.” Most of us dream of having fulfilling intimate relationships. In my value system, this is a good thing. There are boatloads of studies showing that good relationships support better physical health, much less mental health.  We can have personal stories, small or large, that are hopeful, helpful stories.

This comes back to the interplay between how & what we think, how we see things, and how we behave.  There are clearly complex interactions among the three possible avenues to change. But the good news is that it’s possible to start anywhere. At least that’s the story I’m using, because when I act as if it’s true, I can see things differently.


 The image is widely available but this copy was taken from

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Light Therapy for Bipolar Depression

Sorry to have been MIA for so long.  As some who follow the blog may remember, I am trying to keep my promise to focus on original content, but this news item on bipolar depression looked too significant to pass up, especially with the winter upon us. I will try to get a new post out soon.

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Feelings About Feelings

Some time ago I noticed a common problem, or perhaps I should say problem about problems, that many clients shared– People would be down on themselves for being depressed, or angry with themselves about their anger problems, or would worry too much about their anxiety. This, it seems to me, creates a “chasing your tail” mentality that makes it almost inevitable that you will spiral into the very emotion that is bothering you.

I suppose it’s also equally problematic to worry about depression, or be angry about anxiety,  but my purely unscientific observation has been that people tend to spiral in on a particular emotion.

My suggestion on how to break the spiral has always been to start by accepting the reality of the initial feeling: “I’m depressed. That’s how it is for right now.” This acceptance seems to make it easier to move on to the next feeling, even if the feeling is another negative feeling. We have to admit that sometimes life just plain sucks. Any student of statistics and probability will tell you that pure bad luck can sometimes pile up. But accepting the bad prevents (or at least minimizes) rumination, obsession, and general stuckness. It also, in my opinion, makes it possible to be open to the next positive emotion– perhaps in my time of trouble a friend or family member is supportive, or I take comfort in a little thing, like a beautiful sunset, or the friendship of a pet. Getting off the wheel of self-judgment is what opens us up to the next thing– makes emotional life an open system rather than a closed one.

Does it sound reasonable? Well, now there’s evidence. A study cited by the Center for Greater Good found that people who are better able to accept feeling bad end up having fewer mood disorder symptoms. Remember, we all have moods, ups & downs, and there’s no getting out of having bad days, or even bad months. If I’m struggling financially and it’s due to caring for a family member with a chronic illness, not feeling bad at least some of the time that would be very strange. I might be very resilient, have great family or community support, have a strong spiritual practice– and still feel negative moods. Bad things happen to good people. BUT the thing that, in my opinion, makes me much more likely to have a mood disorder is getting caught up in the spiral. The evidence in the article suggests that people who push away negative emotions (denial?) are also likely to have mood disorder symptoms down the line also. So perhaps it comes down to that old standby, acceptance.

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Save That Relationship!

Just took a quick peek at a piece from and wanted to excerpt  my favorite part, as follows:

So how do you increase understanding during conflict? Here are seven suggestions for how to think and act to do so.

Older couple

1.Instead of asserting your own point of view, try to take your partner’s perspective. Make it your goal to understand why your partner feels the way they do.
2.Avoid the four horsemen of the apocalypse—criticism, defensiveness, contempt, and stonewalling.
3.Give your partner the benefit of the doubt. Assume that their intentions are not malicious.
4.Take a moment to reflect on your partner’s positive traits. You can even try some gratitude-inducing techniques.
5.Think of you and your partner as a team, rather than opponents. Your goal is to figure out together why you do not see eye-to-eye and find a solution; it is not to win the fight and prove your partner wrong.
6.Recognize that it won’t always be easy to follow these suggestions, especially if your partner isn’t playing by the same rules.
7.Give yourself a mantra to repeat when you start feeling angry to help you remember your goal—even something as simple as “be understanding.”

Some of the best stuff I have learned about working with couples trying to get the wrinkles out of relationships I learned from a couple who I worked with for a long time despite the high level of conflict in their relationship. I used to refer to them as the  “Killeachothers.” In fact, progress for them meant that they no longer engaged in mutual combat, but merely verbal conflict. They had one of the common problems that couples bring to counseling (from a process point of view): he wanted her to take care of her diabetes better and she wanted him to work on his substance abuse issues. They didn’t do many of the things on the list above. Criticism and defensiveness were big with them, and they frequently acted like opponents. But some of the other things they could do, such as reflecting on the other’s positive traits, and recognizing that change is hard, and they went back & forth on giving each other the benefit of the doubt versus thinking the other was being malicious. But after being brutally stuck for a long time, the thing that really got them moving toward change was a very simple communication drill. I will give it, but it is almost impossible to follow without a third party to act as a communication coach. It is as follows:

  1. First person says something in 25 words or less, but no conjunctions.  For people not into grammar, think of it as no ifs, ands, ors, or buts.
  2. Second person repeats it back, either verbatim or as understood.
  3. First person confirms that the message was correctly understood. (if not, go to step one– see below)
  4.  Second person then responds to the message in the initial format of 25 words or less, no conjunctions.
  5. First person repeats it back, either verbatim or as understood.
  6. Second person confirms message understood.
  7. repeat steps one through six to continue.

note to #3– If the first person says their message was not understood, they have to restate what they said, still using 25 word format, or otherwise clarify the initial statement in 25 words or less using no conjunctions.

People who are familiar with active listening will recognize this as being a very carefully controlled version. It works to smoke out people’s assumptions, interpretations, extrapolations, and plain old distortions. If we think of a normal conversation as being like a movie, this is a way to take it frame by frame– and see where things start to go wrong. The original post from Greater Good points out that people can have a high level of conflict, but if they feel the other understands them, the relationship can still work (my words).

If you want a simpler protocol to follow to reduce conflict & bad vibes while arguing, you can follow the one step laid down by Miss Manners (and a host of others):

  1. Don’t Interrupt. I would expound on this, but do I really need to?

Image from

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Suicide Prevention Awareness Month

Did you know about National Suicide Prevention Week? I must confess that I didn’t, except for the fact that I work in an environment that raises awareness about things like this.  In fact, NAMI has expanded it to National Suicide Prevention Awareness Month.  Many people are not aware that suicide is the tenth leading cause of death in the U.S. While it is a high-ranked cause of death in younger people– who,after all, are relatively healthy and unlikely to die from thinks like stroke or heart disease, the rate of suicide is actually higher in older populations. Similarly, while reports of suicidal ideation are high in the 18-25 age group, the older groups have the higher rates of actually attempting suicide.

Regardless of what age group someone might be in, people do give signs that they may be suicidal, and there are things one can do to respond. The first point that I want to emphasize is that it’s better to talk about it than not. The link has a pretty good basic outline of how to help. I want to add a couple of thoughts based on having lost two cousins to suicide as well as having had many suicidal clients and having lost more than a couple.

No matter how lonely, isolated, and alone you may feel, there are people who care.

When I worked with a population of older, socially isolated, mentally ill, addicted, physically ill, poverty-stricken men– an extremely high risk group– every time someone died from suicide, afterwards there were always people who were saying, “If only I had known–” they would have been willing to be there for the person.  If you are the person considering suicide, don’t make the mistake of thinking/hoping people are mind readers.

Getting high is not going to help.

Again, from my work in addiction treatment, there were many people who would become suicidal when they drank or used drugs. The poster child was one client who really suffered more from alcoholism than depression. In fact, he was in treatment for a suicide attempt– jumping out of a window– which occurred in an alcoholic blackout. When he wasn’t drinking, he wasn’t even depressed. Another person I knew jumped out of a sixth floor window (and lived, with minor injuries) while intoxicated.  There are a lot of statistics out there, but I don’t want to go the number-wonk route in describing this. Getting high doesn’t help anybody’s judgment, and it doesn’t take a pack of researchers to verify it. If you’re making a life or death decision, getting twisted on anything won’t help. If you’re trying to get your nerve up to kill yourself, why not get your nerve up to talk to someone? It’s equally hard, sometimes, but…

If you’re in therapy, use your therapist– if not, get a therapist.

Therapists have spent many an hour exploring with people the most basic question of existence– life or death– and are far less inclined to panic when someone talks about suicide. It has famously been called “a permanent solution to a temporary problem.” This is not inevitably true, but  frequently is true. Depression makes it harder to think, and especially hard to see alternatives. Talk it over with someone if you’re thinking about suicide. There is always the National Suicide Prevention Lifeline– (800) 273-8255.


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