Sunday, September 30, 2012

Not everything is pathological!

Not everything is pathological!  Some of my patients need to be told this repeatedly.  Every session brings a new complaint.  "I had trouble falling a sleep a couple of times last week," one might say.  "I had a nightmare a few weeks ago," another tells me.  "I was really tired on Monday," says another.  Sometimes I recall my own recent experiences and think to myself, "Yeah, I remember feeling tired at least once last week; probably more than once.  And I'm sure there was at least one night when I had trouble sleeping.  It wasn't a big deal." 

Not only are these experiences "not a big deal," they're completely normal.  Who among us doesn't have trouble sleeping from time to time, particularly when we're worried about something?  Who doesn't wake up feeling irritable on occasion?  Who doesn't have a hard time finding motivation to clean the house or run some errands every once in a while? 

At some point we all have these experiences, yet rarely do we become alarmed by them.  Why is it, then, that a substantial minority of my patients find such things concerning enough to bring to my attention?  (At least I assume that's why they share these concerns, since we're there to talk about problems that require treatment). 

When such conerns are raised in session, the first thing I do is to normalize my patient's experience.  I try to explain that not every unpleasant experience is a sign of a larger problem.  In life, I tell them, we all deal with feelings we'd rather not have, events we wish wouldn't happen, and physical aches and pains we'd prefer not to endure.  Such things even occur sometimes without any identifiable reason.  It's important, I explain, to remember that something doesn't have to be problematic just because it's unpleasant.  In fact, labeling something as problematic probably only makes it more unpleasant.

After normalizing, I attempt to help the patient clarify what constitutes a problem and what doesn't.  (While it's not beneficial to classify every negative experience as problematic, neither is it wise to ignore negative experiences that really are problematic). 

So how do we know when something is a problem and when it's just a variation of normal human experience?  When trying to define a somewhat abstract concept, I like to start by consulting a dictionary for a more literal definition.  There are several entries in a standard English dictionary under the word problem.  One entry defines the word problem as "something that causes trouble or difficulty."  Thus, a problem is something that causes difficulty by interfering with your daily functioning or by significantly decreasing your quality of life.  Can you still go to work, pay your bills, or otherwise fulfill your normal daily responsibilities?  Can you still experience pleasure and enjoyment?  Can you maintain at least a few functioning interpersonal relationships?  If so, you're probably doing okay. 

Problem is also defined as "an undesirable condition that needs to be corrected."  The key word here is condition.  A condition is a mode of being or form of existence.  It permeates all aspects of one's life, implying that it exists over a period of time.  Thus, a problem is unlikely to be something that happens just once or even rarely.  Typically, a problem is something that is present over a period of time and in a variety of situations.  (To diagnose a mental illness, the field of mental health requires a set of symptoms to be present for specific minimum periods of time).

Yet another way to define problem is as "something that is difficult to manage."  The implication here is that a problem is something that challenges one's ability to cope.  Those with an average set of coping skills are able to cope with minor annoyances and irritations quite easily.  Something becomes a problem only when a person's usual coping mechanisms aren't effective in dealing with it and the person becomes overwhelmed.

I'm sure I've missed some things and of course, there are exceptions to every rule.  The main point is just that  not everything unpleasant is a problem and that labeling it a problem only makes it more unpleasant.

Sunday, September 23, 2012

Suppressing Emotions

There are people who believe emotions are unnecessary and so seek to distance themselves from their emotional experiences.  There's certainly nothing wrong with gaining some distance from our emotions.  In fact, it's a skill we need if we want to function "normally" in society.  Distancing ourselves from our emotions is only problematic when it becomes our primary method of responding to our feelings.  The eventual result of suppressing every strong emotion that arises is emotional detachment.  To be emotionally detached is to no longer recognize the physiological changes that accompany each emotion.  These changes continue to occur, they just do so outside of conscious awareness. 

At its core, emotional detachment is nothing more than the absence of self awareness.  There are, of course, some who say that ignorance is bliss; you cannot feel pain if you cannot (or do not allow yourself to) feel.  In my opinion, a life devoid of emotion is an empty life indeed.  I cannot imagine living a life without happiness or a life without love.  It is difficult to think one could find meaning in such a life.  And yet, there are those who choose this path; they give up the pursuit of happiness in an effort to avoid pain. 

It doesn't work.  In reality, refusing to engage with our emotions has consequences that go beyond missing out on the richness of emotional experience.  It turns out that actively suppressing emotions impacts our physical health as well.  Several studies have shown that suppressing emotions (both negative and positive) leads to increased sympathetic activation of the cardiovascular system.  When the cardiovascular system is hyper-activated repeatedly over an extended period of time, "such...activation might lead to chronic functional and structural changes of the cardiovascular system that compromise its performance" (Mauss and Gross, from Chapter 4 of "Emotional Epxression and Health: Advances in theory, assessment, and clinical applications," 2004).  Related health problems include hypertension and atherosclerosis, both of which lead to an increased risk of heart attack and "sudden cardiac death." 

Simply stated, chornic emotional suppression is bad for your heart.  Or, as I frequently caution my patients: "If you don't deal with your emotions then your emotions will deal with you."

Sunday, September 16, 2012

Hearing others' stories

Over the years, I've discovered that my patients appreciate consistency.  They like knowing what to expect when they come to see me.  I've noticed that even significant changes to my appearance can be unsettling for some. 

I get it.  People come to therapy when the problems they're dealing with become overwhelming.  Often, their entire world seems unpredictable and chaotic.  Therapy becomes a sort of haven of stability where they can try to sort things out.  The consistency is comforting and provides a sense of safety. 

This works for me.  I too have a deep appreciation for stability.  When I do make changes, it is almost always incrementally.  I like knowing that even if I can't fix a patient's problems, I can at least give him somewhere to feel safe and accepted. 

The first and sometimes only service I provide in this role is to bear witness to a patient's story.  I listen and I validate.  I did not initially realize how important this is.  After all, anybody can listen, right?  Apparently not.  The mission of the clinic I work in is to provide interventions to those who have had one or more traumatic experiences.  A lot of the patients I see have never shared their stories with anyone.  Having the opportunity to talk about what they've been through is often quite powerful. 

So imagine if I were to interrupt their narrative and say, "Stop.  It's too horrible.  I don't want to hear anymore!" It would confirm what they've long suspected: their suffering is theirs to bear, alone.  No one can help them.

All of us at the clinic are aware of the risk for "vicarious traumatization" - being traumatized by someone else's trauma.  I've been lucky; for the most part, patients' stories don't bother me.  Of course I feel bad that they've gone through such terrible things, but hearing about it doesn't unnerve me; I maintain the same steady, reliable presence that my patients have come to expect from me.  For me, tt's almost like when a patient leaves my office he takes his story with him.  I don't hold onto it and I don't really think about it until the patient's next visit.

Something different happened this week.  It was my first session with this particular patient.  She'd seen one of the psychiatrists and was referred to me for therapy.  I wanted to take the initial session to get to know her and to get an understanding of the problems she's dealing with.  About halfway through the session, I asked if she felt comfortable giving a brief summary of her traumatic experiences.  

My patient began sharing her story.  I interjected a few times to ask questions for clarification.  Mostly, I listened.  Everything was fine until the patient reached a point in her story that involved being conscious for a medical procedure in which she lost massive amounts of blood. 

I started becoming dizzy.  Suddenly I felt hot and I began sweating profusely.  (It was literally dripping off of me; when it was all said and done, I noticed that my clothes were wet).  I was lighthead and the room looked like it was spinning.  My patient was still talking but she sounded far away, or maybe muffled. 

It occured to me that I've experienced this sort of thing before.  You see, I have a strong aversion to needles.  For years I used to faint everytime I had to give blood.  Eventually, I discovered that I could prevent myself from passing out if I took deep breaths during the procedure and avoided looking at the needle or the blood.  Still, even now I get anxious whenever I'm faced with the prospect of getting stuck with a needle. 

So here I am in session with a patient and I think I might pass out from hearing her story.  I didn't want to ask her to stop -- what kind of message would that send?  On the other hand, how would she feel if I passed out right there?  To make matters worse, the room was still spinning and I couldn't think clearly. 

Finally, I lifted my hand and said, "Hold on a minute." I tried to recompose myself but it was so hot and I felt so lightheaded. 

"Was it the blood?" my patient asked.

"Yeah," I said.  "Just give me a minute.  I am so sorry."

Eventually, I excused myself.  A coworker's door was open and I slipped into her office.  "Are you okay?" she asked, alarmed.  "Your face is green!  Why are you all wet?  What's wrong?" 

Fortunately, the temperature in my coworker's office was much cooler than that of my own.  The blast of cool air did the trick.  Within a few minutes, I was feeling better.  I ended up going back to talk to the patient.  I apologized and told her we'd meet again next week (if she still wanted to, of course).

I felt like I needed to share this because I didn't want to allow myself to become embarrassed (anymore than I was at the time) about it.  In my opinion, the sooner I can look back on something and laugh, the better.  I've also been mentally rehearsing my patient's story so that I'm ready to hear it when the time comes for her to tell it again.

Sunday, September 9, 2012


It is impossible to go through life without ever experiencing regret, even when we intentionally avoid doing things we'll later wish we hadn't (or intentionally seek to do things we know we'll regret not doing).  We are human; we make mistakes.  Our mistakes beget unpleasant outcomes.  In the midst of coping with the consequences of our bad decisions, it is only natural to wish we'd made different choices.  This is regret: to feel a sense of personal responsibility for the way things turned out and to imagine that things would be better if we'd only decided differently. 

Regret is a natural consequence of being free to make choices.  Studies have shown that the very act of choosing almost immediately leads to regret and causes the unchosen option or options to appear more attractive.  Because there is regret associated with each unchosen option, more options leads to more regret.  Researchers have found that we anticipate this regret and take it into account everytime we make a decision.  When tasked with choosing from a large number of options, the amount of regret we anticipate can seem a bit daunting.  This is consistent with evidence suggesting that the more options we have, the less likely we are to make any choice. 

Of course, deciding not to choose is also a choice.  We opt out of making a decision so we won't have to face the regret associated with the options we did not select.   And so we are spared, at least in the short term.  We have not, however, successfully avoided our regret; we've merely postponed it.  Here I borrow a quote from Gilovich and Medvec: "As troubling as regrettable actions might be initially, when people look back on their lives, it seems to be their regrettable failures to act that stand out and cause greater grief." 

The research gives some credence to my own personal decision-making philosophy.  (Not that the "philosophy" itself was developed with this in mind.  Still, it's nice when there's actual evidence to support the quirky way I do things).    When faced with multiple options, I gather a small amount of basic information about each of them. (Notice the emphasis on small and basic). This allows me to rule out any options that clearly aren't a good fit.  At that point, I am typically left with several equally attractive alternatives. 

The way I see it, if all options are equally attractive then it really doesn't matter which one I choose.  It's unlikely that gathering more information will help.  You see, the more I learn about each option, the more attractive they will all seem.  This will make it more difficult for me to choose one over the others.  So I just pick one.  It doesn't matter how; maybe I'll write them all down on little slips of paper, put them in a bowl, mix them up, and pull one out.   Maybe I'll cut out pictures of them, lay them out in a circle around me, close my eyes, spin around, come to a stop, and point.  Whatever.  I just pick one.  And once I've made my choice, I fully commit to it.  I don't second guess myself.  I don't keep looking for other possible options "just to see" if I could've gotten a better deal.  I make my selection and commit to it; then I move on.

Have I managed to eliminate all traces of regret from my life?  Um, no.  I'm human, after all.  Like everyone else, I'm a work in progress...

Sunday, September 2, 2012

On being an introvert

Sometimes it's hard being an introvert.  It seems like extroverts have all the advantages, at least in today's world.  American society values the characteristics associated with extroversion: energetic, outgoing, enthusiastic, active, willing to take risks, objective, cheerful, expressive.  Extroverts are quick to engage with others.  Because they tend to be action-oriented, they enlist other people in doing things; this shared participation in a common activity provides the context for building interpersonal connections.  Thus, extroverts establish relationships quickly and easily.  People like extroverts and they like to be around them.

Whereas the extrovert is attuned to and energized by the external environment, introverts tend to focus their attention inward.  Introverts spend a lot of time thinking, interpreting, and analyzing.  They often enjoy abstract concepts and ideas.  They typically concentrate well and are not easily distracted.  The extrovert gains energy by spending time with others; the introvert gains energy by spending time alone.  Thus, introverts often withdraw from social situations. 

These are not the qualities that get a person noticed.  They are not the characteristics Americans tend to associate with success.  Americans admire and respect the type of people who can walk into a situation and take charge without batting an eyelash.  They look up to people who appear steady and confident.  In America, the qualities of the extrovert are seen as favorable and are therefore advantageous.

In addition, there is an abundant body of evidence suggesting that extroverts tend to be significantly happier than introverts.  So many studies, in fact, have demonstrated this effect that Lucas, Le, and Dyrenforth call the correlation between extroversion and positive emotion "one of the most robust findings in the study of personality and emotion."  There have even been studies showing that introverts can increase their positive emotion by acting like extroverts. 

And so being an introvert can be difficult.  We're systematically undervalued and frequently misunderstood.  Often, we're encouraged to become more extroverted, implying that there's something wrong with the way we are.  I've seen the impact this can have on people.  Over the years, I've had many introverted patients who came to me thinking there was something wrong with them.  Such is the plight of the introvert living in an extrovert's world.

I briefly saw a psychologist when I was in graduate school.  One of the first things he did was have me complete the Myers-Briggs (a personality assessment).  I remember when we went over the results together.  "So do you think you're an introvert or an extrovert?" he asked before revealing what the assessment showed.  "I don't know," I replied.  "I could see it going either way."  "Actually," he said, pausing.  "You're pretty strongly introverted."  "Really?" I asked, surprised.  I'd always thought of introverts as being shy, reserved, and quiet -- all things I definately am not.  (As it turns out, this is a common misconception). 

Discovering I'm an introvert shed new light on a light of things I didn't understand about myself.  Once I understood these things about myself I was able to embrace them.  I was also more sensitive to what I needed -- plenty of alone time to think and reflect as well as quiet time to regroup after socializing.  Whenever I have a patient who is clearly introverted, I set aside time to help them understand what this means.  I normalize their need for alone time; I explain that making time to be alone is an essential part of taking care of themselves. Hopefully, they will learn to embrace who they are...

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