WillSpirit!


∞ Where Mental Skills Heal Mental Ills ∞

A former physician writes about mental health and recovery using insights from life, science, and spiritual practice.








  • Red_Exclamation_DotDisclaimer
    • Dear Visitors:
      Although I trained and practiced as a physician, my background does not include formal instruction in psychiatry beyond basic medical education. This journal presents ideas about treatment philosophy, but must not be considered therapeutic advice. Abrupt changes in one's psychiatric medications can trigger profound cognitive, emotional, and physical symptoms, including suicidal thoughts and actions. Consequently, pharmaceutical agents should not be increased or decreased without supervision by a mental health clinician.

    • ON THE OTHER HAND, your brain belongs to you, and your opinion counts. If you decide that changing your medication regimen will serve your best interest, then I believe your providers have an obligation to help you try to achieve your goals. I want everyone to be educated about their options, and do what will be most helpful for themselves. No one should feel pushed around by dogmatic and/or limited viewpoints, whether those of psychiatrists, anti-psychiatry advocates, or myself.


Closing the Window on Past and Future

In a meeting last week with my Acceptance and Commitment Therapy (ACT) practitioner, I remarked that worries about the distant future and regrets about the remote past no longer trouble me. For instance, I don’t lie awake nights fearing old age and isolation. I don’t visualize myself slumped in a wheelchair in some nursing home, alone and forgotten. Nor do the choices that led to my lack of children and career haunt me like they once did. It feels wonderful to be freed from mental content that used to terrify and demoralize me.

On the other hand, prior to the past few days, more immediate events remained profoundly disrupting. For some reason, the window seemed to be about six months in either direction. For instance, I felt intensely frustrated by a doctor who has been treating me since January, because he views me through the lens of stereotypes bequeathed by my psychiatric record. I regret placing my orthopedic care in his hands. And part of the reason for my recent psychiatric collapse was my fear of aimlessness in the aftermath of my closing the acupuncture practice. I have no idea what to work on next, but rather than giving myself time to reorganize, I recoiled against my current lack of direction.

But why, I’ve been wondering ever since my ACT session last week, should a six-month envelope keep me captive? If I can release fears about what might happen in two decades and regrets about choices I made a dozen years ago, why not let go of next summer and last winter?

It should be easy to further narrow the window of relevance. If images of loneliness and isolation in old age no longer trouble me, when they once sparked panic attacks, why should I worry about a few months of extra free time? If the decision to move away from San Francisco and take up suburban life no longer seems disastrous, why complain about my poor choice for a new doctor?

The future and the past don’t reside in the brain. There is only the present moment, colored by traces of years past and imaginings of coming events. Both the traces and the imaginings can be consciously reshaped to serve our better purposes. For that matter, they can be left in the hidden matrix of latent neural patterns rather than pulled into current awareness.

I’ve enjoyed a new feeling of spaciousness over the past couple of days as a result of this realization. It seems to me that the difficult work of letting go of deep past and distant future makes this shift in attitude toward more immediate events rather easy. It only requires that I exercise my ability to determine what gets pulled into awareness and how my thoughts frame reality.

As often happens, a serious (though brief) psychiatric crisis forced me to reassess my mental life and update my strategies. This is the value of pain, I believe: it stimulates growth. Our task is to quit fighting and start learning.

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Closing the Window on Past and Future was published on May 14th, 2012 . 4 comments






Rising Up Again After a Fall

One day in kindergarten, the teacher taught us how to cut a circle out of construction paper. We were making cards, or posters, or something, and we each needed a red round. She started with a square piece of paper and cut off the corners. This led to an octagon, and she cut the corners off that. She continued cutting the increasingly obtuse angles until she held a pretty circle in her hand. It was obviously an efficient method, perfect for five-year-olds.

But I wasn’t buying any of it. The method looked too mechanical, too slow. Why not just cut the shape freehand? Which is just what I did. Or tried to do. Instead of a four-inch diameter circle, I ended up with a two-inch ragged pear. It proved impossible for me to cut a circle by eye; no matter how many times I went around it with scissors, my creation looked anything but circular. The teacher, rather smugly I thought, used me as an example for what happens when you don’t follow directions.

I have always had a hard time doing things the way everyone else does. I’d like to blame my father’s ranting against “the establishment,” but it seems unlikely that his politics were to blame for my contrariness in kindergarten. My refusal to follow normal patterns probably contributed to later career misadventures, relationship difficulties, and health problems. It would have been so much easier to choose the field of study I enjoyed rather than one that seemed more impressive. My life would now be richer if I’d focused on raising a family rather than neurotic fears. My health would be better if I’d never wasted time with marijuana, alcohol, and so on.

Some people seem blessed from an early age with knowledge of what’s important in life. A good friend of mine in college happily pointed out pregnant women, because he was so interested in starting a family. Nothing could have been further from my mind at that time. He now has three delightful offspring, and I have none. Other friends chose careers they felt passionate about, and some have achieved significant success as a result of their healthy decisions and years of perseverance. I, of course, find myself in retirement at age fifty-three.

So there has been a price to pay for nonconformity. Many prices, in fact. But today, it makes more sense to focus on what was gained instead of what was lost. By operating outside the mainstream, I’ve learned that life can be valuable even if it doesn’t follow the healthiest path. I’ve found that although a family and satisfying career no doubt help one find satisfaction, they aren’t essential. Even in the midst of pain and disability, life remains fascinating and often beautiful.

So although I’m prone to break down and often feel discouraged by my fate (which I admit to having shaped by my own choices), I spring back soon enough. And each time I rise up from despair I feel less tainted by it. Learning that the mere process of living is enough, no matter what goes wrong or how much it hurts, is of inestimable value. It leaves me ever more certain that I will weather whatever destiny may hold in store for me.

You have a right to be skeptical after my last essay. How can someone who entertains suicidal fantasies claim resilience in the face of hardship? My only defense is to say that resilience doesn’t imply that one is upright and rigid like an obelisk. Instead, it suggests the suppleness of a sapling, which can be flattened nearly to the ground by blasts of wind, but then springs upright once the storm clears. Having been knocked down countless times by circumstance, I now feel confident of my ability to bounce back.

And let me emphasize that this has been a learned skill as much or more than an ingrained trait. In younger years a single perceived rejection could lead to weeks of self-contempt and withdrawal. Nowadays I can ride out debilitating pain, humiliating treatment by a new doctor, utter cluelessness about my purpose in life, and still feel fairly happy to be alive once I get the initial tantrum out of my system.

Whence this ability to find satisfaction in the face of discomfort? It came from meditation, introspection, writing, and practice, practice, practice. Luckily, life has provided me many opportunities to develop a talent for rising up again after pain, disappointment, and despair knock me down.

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Rising Up Again After a Fall was published on May 11th, 2012 . 5 comments






Where Do We Want to Live Our Lives?

On a comment left at Storied Mind, a great blog and depression resource created by John Folk-Williams, I mused about whether or not depression is an illness.  (A recent post on this site covered the same question from a different angle.) What follows connects my reply to John’s essay with Acceptance and Commitment Therapy (ACT), which WillSpirit readers have heard me discuss many times before.

John focuses on ACT in his essay and only mentions the illness question in passing. The issue comes up because the ACT view of mental symptoms contradicts the biological disease paradigm of conventional psychiatry.

ACT is based on behaviorism, a philosophy that dominated psychological study in America for much of the early and mid-twentieth century. By the 1980′s behaviorism had been supplanted by cognitive science, a movement that was driven by neurobiology’s computational model of the brain. Behaviorism suffered intense criticism after falling from grace.

The backlash was so thorough and effective that when I first learned that ACT is a behaviorist approach, I assumed it succeeded despite that heritage and not because of it. Behaviorism has a reputation for being overly mechanistic and dehumanizing. The common caricature is that it rejects the importance of mental life and views people as automatons who don’t choose their actions but only react to environmental contingencies.

In his 1974 book, About Behaviorism, B.F. Skinner (the most prominent leader of the movement) defended his views. The text more often assumes than establishes the basic foundations of its philosophy; it insists that  inner life is a consequence rather than a cause of a person’s interaction with his or her environment but doesn’t provide much supportive evidence (although subsequent research has bolstered such assertion). So the book isn’t terribly effective as a counterattack. But it does demonstrate that Skinner looked at human behavior with an admirably practical eye.

In managing depression and other psychiatric symptoms, it is this practicality that makes a behaviorist approach effective. CBT (Cognitive Behavioral Therapy) has trained many of us to challenge negativity. But thoughts arise rapidly and seldom cooperate with attempts at control. Positive thinking is a great concept, but every uplifting thought is dogged by its counterargument. The affirmation, “I’m a good person” seldom can escape whispering rebuttals like, “but remember the time you…”

I don’t deny the helpfulness of monitoring thoughts to weed out inaccuracies and unfair self-criticism. But CBT assumes that feeling is a result of thinking, and that we can feel better if we think better; both these premises are questionable. Thinking and feeling are internal processes that mutually interact and respond to environmental input; thinking isn’t the sole determinant of how we feel. And we all know from experience that positive thinking by itself never resolves a deeply entrenched depression.

But the real problem with CBT, and most other therapies, is precisely that they teach us to focus on thoughts and feelings as we battle mental difficulty. If we are stuck in a deep funk and spending our days in bed, we are taught that if we adjust how we view our childhood, or how we think about our current situation, we will soon feel better. Having established a sunnier inner landscape, we’ll want to get up and live our lives again. Sadly, most of the time the sun simply refuses to shine no matter how much we rethink our past or challenge our negativity.

Skinner would reply that our staying in bed results from learning, not from thinking or feeling. Something in our environment has taught us that lying down pays off. Maybe we get sympathy. Maybe we avoid facing stress. There is a reward that sustains the behavior despite the fact that it undermines our progress in life.

The answer to depression isn’t to wait for our inner state to improve while we do little to alter externals. Rather, we should act on the outer world, which will provide new consequences and teach us better behavior. If I attend a community picnic when depressed, two benefits accrue: I interact with others and so increase my social connections, and I spend some time outdoors. These positive outcomes, especially if repeated a few times, will teach me to adopt similar outgoing behavior in the future. Waiting for the depression to lift before attending such an event would win me neither more friends nor contact with nature. My future behavior would be unlikely to change.

Which finally brings me to the substance of my comment on Storied Mind and the question of whether depression is an illness. Here is an excerpt:

…whether depression is an illness or not [is] a semantic question, and it can have different answers depending on one’s stage in dealing with the problem. If ‘illness’ means a condition that feels unpleasant and limits life, then yes, depression can be (and usually starts out as) an illness. But if it means a definable brain disease that can be treated with specific medications, one can only say that at this point there is little evidence to support that view. I’ve followed this research for years and have yet to see any findings that solidly (or even plausibly) demonstrate organic pathology. For every suggestive piece of evidence one can find powerful refuting arguments.

Although the disease concept helps relieve us of shame and so can be helpful early on, eventually we want more than escape from blame. We want better living. ACT offers an approach to achieving that…  what works is living life with purpose without so much emphasis on how [we] feel or what [we] think…

I no longer react reflexively out of fear, anxiety, insecurity, or negative self-talk. As I’ve begun to live a richer life despite my frequent feelings of sadness, regret, and fear, I’ve started to see that the ‘illness’ concept no longer serves me as it did earlier…

I would add, in light of the behaviorist perspective, that if the answer to depression lies in interacting differently with the environment, then it seems unlikely that the problem resides in the brain. Instead the difficulty is, and has always been, a consequence of the world around us and how it’s taught us to respond to circumstances. This is a radical concept when compared with the traditional view on mental distress. It takes the problem out of the realm of thoughts and feelings and places it in the real world. And isn’t that where we want to live our lives?

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Where Do We Want to Live Our Lives? was published on April 5th, 2012 . 5 comments






Embracing and Accepting Life Despite Its Pains

rippleReflection

The post I planned to write today will come later.

For the past several months a counselor practicing Acceptance and Commitment Therapy (ACT) has been teaching me to expand my philosophy, and quit struggling against my hardships. My insurance granted pre-payment for twenty sessions, and I have completed 12 or 13 so far. My relationship with this clinician started at a propitious time, and dovetailed with my involvement in Bipolar Advantage, which teaches one to take a more positive attitude toward mood fluctuations. These two influences spoke to my gathering awareness that being frustrated and unhappy with ‘the way things are’ serves me poorly. They also bolstered my resolution to wean myself off as much medication as possible, a step made more essential when I awoke to the horrific damage psychiatric drugs have wreaked on my body.

This therapist’s work underlies much of what I write about accepting life’s deprivations, acquiescing to grief, and appreciating the sublime qualities of emotional distress. Knowing that outside of the sessions this person has kept up with my blog posts, and sends me insightful comments on how they relate to my individual story, adds to my feelings of gratitude. I wrote a letter (actually an email) of thanks this morning, and ended up sketching part of my core emotional landscape. Posting a slightly revised version of my message on this site offers my audience a view of my inner milieu, while at the same time publicly expresses my appreciation. Knowing that others share your experience can be very healing. I hope that one or more of my readers will resonate with my longstanding ambivalence about life, and also my growing desire for more engagement. ACT teaches, among other things, that while we all undergo times of distress and cataclysms of sorrow, we can remain open to common joy. Even more, during those shaded times when our days feel bleak and fortune has violated all its promises, it remains possible to enjoy being alive. Perhaps it is akin to loving one’s child even as he spits hostile words at you. He may not be pleasant, but he is still an infinite gift.

A large segment of the population staggers under a burden of emotional agony. If that were not so, investors in pharmaceutical stock would not be so well rewarded. No doubt people have always been afflicted by almost unbearable feelings, but in this era of education, abundance, sanitation, and comfort, I believe we can do better. Not that the pain will go away, but perhaps our appreciation of day-to-day reality can increase. Imagine a world where even in the midst of wage-slavery and fears of violence people relished being alive. Where they accepted their pain to the point that they had energy to fight against injustice. Where financial and material trappings became less important than human relationships and creative expression. The way to achieve this vision lies in opening up, ‘sharing experience, strength, and hope’ (as they say in Alcoholics Anonymous), and collectively learning how to thrive in the midst of a challenging world. I try to do my little part by deconstructing my rusted and creaking mental mechanisms to a behavioral health audience and handing on the tools and lubricants others have provided to help me get things running more smoothly.

This therapist gives me much in this regard. I publish this letter as a public statement of gratitude, with the prayer that programs and messages such as ACT will propagate outward into our culture, like the rings stretching away from a pebble pitched into a pond. Where the surface of my depression once looked as solid and impenetrable as a pane of glass, ACT shows that all pain has depth and rhythms, and that I can learn, grow, and even enjoy myself while exploring these textured realms. Of course, the ideal often lies beyond my grasp. My ability to take such a philosophical stance, and savor the warm sensation of blood pumping from my wounds, depends on practice and motivation. But I have been fortunate to meet someone who has had the patience to sit with me as I bleed, until I understand that unlike the blood that flows through my body, the blood of the soul is infinite. No matter how much I hemorrhage, I will always have the vital spirit to go on, if I choose. So much better than my previous experience in the mental health world, where the philosophy has always been to apply pressure and tourniquets. Sure, drugs can slow the rivers of emotion, but once you tighten the tourniquet the limb goes dead.

I place the letter here because it is more personal and less intellectual than much of what I write. I want to allow people to get to know what I’m really going through, rather than always hiding behind a facade of philosophy, analysis, and weak attempts at lyricism. Fact is, I am making progress, but slowly. I see the path ahead, but have yet to walk most of it. This message shows one footprint along the trail.

Dear [M],

I’m glad that my last blog post provided, at last, some good news in regard to my mental state.

Contemplating death as a solution has always seemed reasonable to me, given how my mother checked herself out of life as I watched. In the suicide hotline we always ask about prior suicidal behavior; I’ve only made a few weak attempts, none of which had a high likelihood of lethality. But suicidality has become a part of who I am. Even twenty years ago I was pretty sure I would some day kill myself. Obviously I have not, and may never, but I no longer feel alarm about thoughts of destroying myself. I think that attitude helps me support people who call the hotline in crisis.

On the other hand, I respect that such talk upsets others. I wish when in my worst moods I could censor my statements better. In particular, it is hard on Mandy to know how often thoughts of death go through my mind (not that I talk about it all the time, but it only takes occasional mention to make the problem apparent). Accepting that life brings pain, and that pain can be endured or even seen as a kind of beauty does not automatically translate into a desire to keep experiencing it. I am OK with that disconnect, but I am not so pleased that my ambivalence about life pollutes the happiness of those around me.

Back to today. Bottom line is I feel better, and happy to keep going. I truly do have a commitment to stay around for Mandy, and I would never leave my dogs unprotected. I even look forward to the future, no matter what it brings.

Thank you for paying attention, and supporting me as I work out a philosophy and mind-set that will carry me through the last several decades of my life. I need to have some kind of framework to both endure and see positive aspects to further declines in health, increased physical pain, and the probable loneliness that await me. Having a deteriorating neck that hurts all the time, and threatens the integrity of my spinal cord, plus knowing how few close relationships I have other than my marriage, does not give me a rosy picture for the future. I appreciate that ACT is not about convincing myself that my fears are unfounded (they aren’t), but rather gives me at least a glimmer of hope that I can survive the struggle. There is even that astounding suggestion that no matter what happens, my future can be enriching and full of adventure.

I look back at what I’ve written here and almost laugh at myself: this is how I think when my mood is more or less good (although I’m realizing my spirits are not as upbeat as yesterday). I don’t know how you feel about getting saddled with me for twenty sessions, but it has helped me that you have been so understanding. And I am thrilled that there is at least one person reading my blog who really ‘gets’ what I’m writing about. Of course, it’s not surprising that you do get it, since you taught me much of what I’m saying. What’s nice is that you’ve taken the time to read how I’ve been thinking about the acceptance philosophy. (You’ll note that I don’t do much with commitment, at this point. I need to more fully commit to staying alive before I can talk with any authenticity about fidelity to values, etc.)

To try to end on a positive note, I am highly motivated to search for reasons to stay alive, and to be glad I am. I want to build something more than a stoic fortitude to not abandon Mandy. Writing helps me feel good about breathing and thinking. Knowing that you (and hopefully a few others) find what I produce interesting makes it even better. In the end, creating something attractive and worthwhile out of tragedy and sorrow has been the task of artists throughout the ages. After decades thinking of myself as primarily a scientist, I now see that creative expression will be my salvation. That requires the knack of appreciating the heavenliness of heartache, which you and ACT have taught me.

Thank you.

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Embracing and Accepting Life Despite Its Pains was published on August 15th, 2009 . 2 comments






What A Lifetime of Therapy and Self-Help Hasn’t Taught Me

AACA Cartoon

What does it take to transfer understanding in the rational part of the brain to the emotional part? The number of years I’ve spent in therapy, or support groups, is vast. Here’s a partial list of the therapy:

  • 15 sessions with a court-ordered counselor when I was sixteen.
  • 12 sessions with a PhD psychologist in college, after a suicidal gesture atop the campus bell tower.
  • 180 sessions with another PhD psychologist, who called himself a behaviorlist.
  • 20 sessions with a counselor in medical school, as I went through a divorce.
  • 24 sessions with a Jungian analyst.
  • 150 sessions with a psychiatrist during residency, who mostly had me talk about family-of-origin dynamics.
  • 250 sessions with a psychiatric nurse who specialized in recovery from child abuse
  • 20 sessions with a counselor who practiced sand tray therapy, among other things.
  • 2 psychiatric hospitalizations, of 12 days and 8 days.
  • 300 sessions with a psychiatrist who took me (again) through family-of-origin dynaymics
  • 100 days or so in intensive outpatient treatment.
  • 20 sessions or so with a social worker specializing in Cognitive Behavioral Therapy) CBT and mindfulness.
  • 12 sessions with a social worker specializing in Acceptance and Commitment Therapy (ACT)–ongoing.
  • Recent sessions with a social worker to deal with history of sexual abuse, and how damage from medication brings that up. (long story to be dealt with in another blog)

And here’s a partial list of the support groups:

  • Support group of medical students weekly for 18 months in medical school, then occasionally for 2 years.
  • Alcoholics Anonymous since 1987. Countless meetings.
  • Alanon since 1988. Countless meetings.
  • Adult Child of Alcoholics meetings weekly for one year while living in Manhattan. (These groups were often hard to take)
  • Adult Survivor of Child Abuse meetings weekly for two years.
  • An eighteen month intensive group therapy for child abuse survivors.
  • Numerous meetings, sporadically attended, of other 12-step programs (e.g., debtors anonymous, sex and love addicts anonymous, etc.)
  • Weekly meetings of a dual recovery group for 2 years ’06 to ’08.
  • Weekly meetings for people with a history of problems with prescription drugs, ’06-’08.

Now, you would think that after all that I would not spin out because my blog-stats dropped. But I did. So how do I take all the knowledge that I really do have about codependence, abandonment issues, self-esteem, acceptance, etc, and make myself well? How come it is so easy to know something with my mind but remain completely clueless in my heart? Is there anyway to transfer the knowledge? Can I build some kind of high-speed data connection between the two parts of my brain that deal with these things? (Aside: Don’t you just hate brain/computer comparisons?)

The only solution I can find is looking for improvement (‘progress, not perfection’ is what they say in AA). Yes, I did crash and burn about the web statistics, but I pulled myself out of it pretty quickly. I was even able to see the humor in my response. That is much better than ever before. What’s more, I opened up about what was going on with me, reached out for help, and was rewarded by many kind messages from those who’ve been reading my posts. (And this was true even though I’ve only been doing this with any regularity for 3-4 weeks; a real testament to the kindness of those who read mental health blogs.)

Thus, I look for signs that my emotional skills today are more honed than yesterday. But I am still puzzled about why I’m so dense. Therapy ‘should’ help the emotions. The unconscious ‘ought’ to learn, but mine obviously did not. Or maybe it sometimes learns, but other times forgets. One way or the other, I find my theoretical understanding far surpasses my practical application of what I know about how to be healthy. Hence, I find it easier to give advice than to live in a state of emotional balance and spiritual connection. It would be easy to blog about all the stuff I’ve been told, and never mention that it only works for me half the time. But that would not be honest, or fair, or helpful to others or to me. So here I am, admitting that the simplest things still trip me up, even though I was fortunate enough to have good insurance, the resources to pay for what insurance would not, and to live in an area with a surfeit of recovery and therapy groups.

I’ll end by asking if anyone knows some tricks for taking cognitive understanding, and turning it into emotional maturity. I am anxious to grow out of this phase and into something more enduringly healthy.

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What A Lifetime of Therapy and Self-Help Hasn’t Taught Me was published on July 28th, 2009 . 13 comments






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