Book review: Shattered

Book cover: Shattered by Patricia J Grace

In Shattered: A Memoir, Patricia J Grace tells her story of the lasting impact of childhood sexual abuse.  This abuse occurred at the hands of multiple brothers, as well as others, after the death of her father.  While her mother was aware of the abuse, she did not intervene to try to stop it.  In fact, when she became infected with public lice, her mother gave her DDT to apply, adding that her brother had already been treated.

Patricia writes about the body image issues she developed as a result of the abuse.  She believed fat=ugly=safer, although of course it didn’t work out that way.  As an adult, her weight continued to rise as attempted to fake her way through her various role functions.  Her mother pressured her to have weight loss surgery, and she went ahead with this.  She later realized: “Without changing the internal messages of badness or dealing with the fear of others, I would continue to turn to food and fatness to feel safe.”  This reminds me of Roxane Gay’s book Hunger, in which she wrote about overeating to seek safety, and try to make herself less vulnerable to abuse.

Patricia eloquently describes the psychological torment that resulted from the abuse she experienced.  The abuse battered her sense of self, leaving her feeling like “a ghost of a person undeserving of the same rights, voice, or worth as others.”  She had learned to remain silent, and she felt emotionally stunted and without a centre.  She felt “trapped alive in a coffin with nails hammered down, scraping and clawing for a way out, fighting for a life with my head up and heart full.”

The difficulties Patricia faced in getting effective therapy will sound sadly familiar to many.  It was challenging to overcome the taboo and break the unwritten rules of silence instilled in her.  Heartbreakingly, like so many other childhood abuse victims there was also a great deal of guilt, “as if I were the abuser not the victim.”  One therapist commented “oh, so you were a precocious child” when Patricia disclosed her childhood sexual abuse.  Another would regularly disrupt sessions to take calls on his cell phone.

I find it so gut-wrenching to hear how even non-abusing parents can be complicit in covering up abuse and allowing it to happen.  Unlike her brothers, who were trusted to maintain silence, Patricia’s mother “needed to work diligently in shaping me”.  She explains simply that “It’s not hard to silence a child. Just threaten to abandon, not in words but in actions. Do this, you’ll be loved. Don’t and you’re not.  The message hit home over time. It took repeated lashings of, “You should be ashamed of yourself” to brand that scar into me, burned so expertly into the template of who I was to become that shame replaced wholeness like a headstone.”  Her mother even went so far as repeatedly pressing her to forgive one of his brothers, minimizing what he had done to her when she was a child.

She explained how she became split in two, with a part of her that remembered and a part of her that had repressed the memories until they became inaccessible.  She felt like Humpty Dumpty with no idea how to put herself back together.  In the end, it was Buddhist meditation that helped for to find peace and connect with herself.  She has come to accept that what happened is inescapable.  She writes that “Moments of peace, internal connectedness, and the late blooming birth of self-acceptance make aliveness worthwhile.”  She has found that she is worthy, and she is okay, and this really is an amazing story of healing.

 

You can find Patricia on her blog Grace to survive

 

Image credit: Amazon.com

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How trauma-informed practice can improve mental health care

person lying on the floor in a dark room

So, what is it to be trauma-informed?  Trauma-informed practice recognizes the intersectionality of trauma, mental health, and substance abuse, and involves an awareness that anyone may have experienced trauma, whether they have disclosed it or not.  Trauma-informed practice aims to create environments that prevent re-traumatization and promote a sense of safety.  The individual client’s safety, choice, and control is prioritized throughout services, and an approach of collaboration, learning, and building trust is used.  There should be a non-hierarchical and supportive organizational culture, and there is a focus on strengths and building resiliency, and hope that recovery is possible.

One area where being trauma-informed has the potential to make a huge difference is when it comes to seclusion and restraints.  The use of seclusion and restraints can lead to significant psychological or physical harm, and can be a major source of traumatization or re-traumatization.  The British Columbia Centre of Excellence for Women’s Health identified several strategies for a trauma-informed approach to seclusion and restraints:

  • staff training in de-escalation
  • have comfort rooms with low sensory stimulation
  • promote the development of crisis plans or advance directives to identify triggers and preferred interventions
  • assess for and address any unmet needs that may be influencing behaviour
  • debriefing following any use of seclusion or restraint to identify why it happened and what was learned.

When I was doing my masters degree one of my classmates was working in a psychiatric intensive care unit where they had instituted changes in their approach to seclusion and restraints in order to provide trauma-informed care.  My classmate had nothing but good things to say about this, and the unit had achieved very significant reductions in trauma and restraint utilization.

My most memorable occasion of being in seclusion was when I had taken myself into hospital, with the support of my community psychiatrist, and said that I was feeling suicidal and needed ECT.  They decided to commit me under the Mental Health Act and put me in seclusion, even though I had gone in voluntarily.  When I was informed I would be locked in seclusion I asked to be sedated, because I didn’t want to be trapped with nothing but my thoughts.  The nurse said there was nothing ordered.  I asked if it would make a difference if I told her that I’d throw my tiny tube of hand cream at her.  She disappeared, I heard a “code white” (aka violent patient aka me) being called over the PA system, and she returned a few minutes later with a bunch of security guards to give me the injection I’d asked for in the first place.  How very therapeutic.

Sometimes in the field of mental health care certain approaches or practices will become buzzwords, and many organizations will jump on board.  I think this has happened, at least to some extent, with trauma-informed practice, and it’s generally seen as something desirable.  Where the problem lies, though, is that there’s a difference between claiming to be trauma-informed and actually being trauma-informed.  I’m sure that the mental health and addictions program I work for would claim to be trauma-informed, just like they claim to be recovery-oriented.  But in practice, it’s just lip service, although I highly doubt the people running the place would see it that way.

I think all mental health care organizations should be trauma-informed, but it’s essential that it look trauma-informed from the client perspective, not just the staff or management’s perspective.  While individual care providers for the most part try (with varying degrees of success) to be empathetic, it’s difficult for some clinicians, and particularly for organizations, to have any real understanding of what the client perspective looks like.

Would you consider the mental health services that you’ve accessed to be trauma-informed?

 

Sources: British Columbia Centre of Excellence for Women’s Health Trauma-Informed Practice Guide and Trauma-Informed Approaches to Seclusion and Restraint Reduction

 

Photo by Hailey Kean on Unsplash

How can we help those in mental health crisis?

"help me" marked on a foggy window

Recently I did a post expressing my concern about learning that a local police force routinely handcuffs people that they are taking to hospital under a Mental Health Act apprehension.  That got me thinking about what it shoulds look like to help people in mental health crisis.

The police force in the city where I live (different from the one referred to in my previous post) has a partnership with the local health authority to operate what’s referred to as car 87/88.  This involves an unmarked police car, a plainclothes police officer, and a mental health nurse.  They attend mental health emergency situations, and track down people who have been certified under the Mental Health Act in the community but left before they could be taken to hospital.  If they’re attending a call and someone needs to be taken to hospital involuntarily, either the police officer will do a Mental Health Act apprehension or the on-call psychiatrist will be called to assess the person and do a Mental Health Act medical certificate if appropriate.  An ambulance is then called, and the person is transported to hospital in the ambulance, with the car 87/88 police officer accompanying as needed and the nurse following behind in the police car.

I really like this system, and the biggest problem I see is that there is only one car for afternoon shift and one for night shift in a large urban centre.  It seems much more civilized to have a more subtle police presence (unmarked car, no uniform), a highly experienced mental health nurse, and transportation in an ambulance (what with mental illness being a medical issue).  I understand why police need to be involved sometimes if someone is being taken to hospital on an involuntary basis, but I don’t think that’s any excuse to take the health out of health care.  Mental illness crisis is an emergency medical issue, and I strongly police should be involved in a primarily supportive role unless there is an imminent safety risk.

Speaking of which, I think it’s crucial that police attending situations where a mentally ill person poses an imminent threat be well trained in the use of less lethal force options, such as weapons that fire rubber bullets or bean bags.  A number of years ago at a mental health clinic where I worked, a client had come in who was highly suicidal and wished to commit “suicide by cop” (i.e. goad police into shooting and killing him).  The team of police officers that attended handled the situation extremely well trained and were able to utilize these less lethal options to make sure that nobody got hurt, including the client.

Because mental illness is unpredictable, mental illness crisis situations are equally unpredictable.  However, I think having a well-designed crisis response system can go a long in in both promoting safety and preserving dignity of the mentally ill person in crisis.  A system that further traumatizes mentally ill individuals does no one any favours, and we need to do better than that.

 

Image credit: Kaz on Pixabay

Book review: I Am the Architect of My Own Destruction

book cover: I Am the Architect of My Own Destruction by Juansen Dizon

I Am the Architect of My Own Destruction is Juansen Dizon’s second book of poetry.  The book opens with a letter to the reader, which begins “It’s hard to write when you want to kill yourself. It’s harder when you don’t really know the reason as to why.”  Throughout the book I felt like I as a reader was being directly spoken to.

The poems capture the darkness and depth of mental illness, and often I was left thinking wow, that’s exactly how I have felt.  Thoughts of suicide are shared in a way that feels very genuine and non-triggering.  The book touches on a range of topics including body image and the difficulty of self-love.  Along with the difficult part of mental illness, Juansen also writes about healing and happiness.  This provides a good balance to some of the darker poems.

Many of the poems were quite short, which I really appreciated because as I was reading the book depression was doing a number on my concentration.  Some are only one line, but carry profound meaning in those few words, like Numb and Casket.  I was impressed by the emotional depth that could be captured in just a few words.

The book explores love and navigating relationships, and how challenging this can be when in the depths of mental illness.  Juansen clearly bares his soul as he writes about this.  The book also includes touching letters to his girlfriend and his brother.

I particularly liked the one-line poem Seraphim: “Melancholy is an angel that fell in love with a demon.”  Another favourite was Warriors, which talks about the strength it can take to stay alive.

This book carries the reader on a poetic journey into the author’s mind and heart, giving an intimate look at the experience of mental illness.  The poems are very accessible, in the sense that even people who don’t normally read much poetry would likely find it easy to engage with this book.  It’s well worth checking out.

 

You can find Juansen on his blog Lonely Blue Boy.

 

Note: I was provided with a free copy of this book in exchange for an honest review.

Image credit: Amazon.com

My experiences of going off meds

red pills in the shape of an X

I have never had  a problem with medications in general, and in my work as a nurse I’ve seen how much good they can do.  Despite that, I’ve gone off the meds I take for depression a few times, and that’s what this post is about.

My first episode of depression was in 2007.  I ended up hospitalized following a suicide attempt, and spent 2 months in hospital.  I continued taking my meds for a few months and I then I had another suicide attempt, this time by overdosing on my psych meds.  I didn’t do any significant damage, so I chose not to tell anybody at the time.  I decided that to hell with it, if I was on meds and still feeling shitty, what was the point of continuing meds?  Continuing on my deceptive theme, I didn’t want my treatment team to know I wasn’t taking meds, so I continued to pick them up regularly from the pharmacy.  I ended up getting into full remission without meds, and I remained well for almost 4 years.

My plan all along was that if I started to have signs of getting worse, I would restart meds.  When the depression started to hit me in 2011, I quickly recognized the red flags of poor sleep and low mood, and made an appointment to see my GP.  I had to practically beg for meds, and he begrudgingly gave me 10mg of citalopram, although his preference was that I attend group therapy.  2 weeks later I ended up in hospital.

It took a year and a half to get fully well again, and I ended up on multiple weight gain-inducing meds (lithium, quetiapine, and mirtazapine).  The weight gain was hard to adjust to, although I recognized it was probably a fair price to pay for being well.  After 2 years in full remission, I decided I wanted to try going off the quetiapine, and my psychiatrist was agreeable.  We tapered down the dose gradually, and at first it seemed like I was going ok, until suddenly it wasn’t.  I got really slowed down, and ended up having to go back on the quetiapine as well as up my dose of lithium.  Clearly I needed my full med cocktail.

It wasn’t too long afterwards that my workplace bullying debacle began.  This culminated in me deciding to quit my job, and I became quite depressed again.  My psychiatrist ‘s reaction was tremendously invalidating, so I stopped seeing him.  I had recently begun seeing a new GP, and when I told her why I wasn’t seeing the psychiatrist any more, she came out with the same invalidating comments he did.  I refused to see her again, so she booked me in to see another GP at the same clinic, who ended up being even worse.  I couldn’t bear the  thought of going to see another doctor, so I decided that with the meds I still had at home I would do a gradual taper and then stope them.   It wasn’t that I wanted to stop taking meds, I just wasn’t willing to see another doctor.  Not surprisingly, that strategy didn’t work out very well for me.  I was barely sleeping despite taking everything over-the-counter I could think of.

It was when I decided that I needed to go back on meds that I found my current GP, who’s very reasonable and pragmatic.  Even so, there have been a couple of times that I’ve thought screw it, there’s no point going in to get my meds reordered because I just feel like crap anyway.

My logical mind is very adamant that I need meds.  Unfortunately, sometimes depression sneaks in and twists things around, and for me I don’t think that’s something that will ever go away no matter how pro-meds I am most of the time.

Have you gone off meds before?  What was the experience like?

 

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Why isn’t Complex PTSD in the DSM-5?

woman partially hidden behind a curtain

While many sources of trauma are time-limited, some occur repeatedly over prolonged periods of time.  The term complex PTSD is used to capture the profound psychological harm these people exposed to the latter have experienced, including changes in self-concept, problems with emotional regulation, distorted perceptions of the perpetrator, and impaired relationships with others.

There are two major diagnostic symptoms used in psychiatry.  These are used to standardize diagnostic criteria, and are used for such things as insurance billing.  The American Psychiatric Association puts out the Diagnostic and Statistical Manual (DSM), which is currently in its 5th edition.  It is the diagnostic system that tends to be used in North America.  The World Health Organization publishes the International Classification of Diseases, which is now in its 11th edition, and it is used in various areas worldwide.  The recently released ICD-11 considers complex PTSD to be a distinct diagnosis from PTSD, but the DSM-5 does not.  Why is that?

According to the ICD-11, complex PTSD is:

“a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible… The disorder is characterized by the core symptoms of PTSD; that is, all diagnostic requirements for PTSD have been met at some point during the course of the disorder. In addition, Complex PTSD is characterized by:

1) severe and pervasive problems in affect regulation;

2) persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the traumatic event; and

3) persistent difficulties in sustaining relationships and in feeling close to others.

The disturbance causes significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”

There were a number of changes in the diagnostic criteria for PTSD in the DSM-5 compared to the DSM-IV.  The DSM-5 added a symptom cluster of negative alterations in cognition and mood, along with symptoms related to intrusion, avoidance, and alterations in arousal and reactivity.  This new symptom cluster includes:

  • “Overly negative thoughts and assumptions about oneself or the world;
  • Exaggerated blame of self or others for causing the trauma;
  • Negative affect;
  • Decreased interest in activities;
  • Feeling isolated;
  • Difficulty experiencing positive affect”

There is some overlap with the symptoms described in the ICD-11, but the DSM-5 doesn’t seem to fully capture those symptoms.

According to the National Center for PTSD, complex PTSD was not included as a separate diagnosis in the DSM-5 because 92% of those with C-PTSD also met the criteria for PTSD.  A review of the literature by Resick in 2012 found insufficient evidence to support complex PTSD as a distinct diagnosis from PTSD as defined in the DSM-5.  This is in spite of a significant body of research literature supporting complex PTSD as a separate diagnosis.  For example, a study by Powers et al. of African women found “clear, clinically-relevant differences” between the two conditions.  C-PTSD was associated with lower likelihood of having secure attachment, greater comorbidity with other mental illnesses, increased emotional dysregulation and dissociation.

Of course the DSM needs to consider research evidence in making decisions about what diagnoses to include, but I’m concerned that their choices with regards to research findings may have been biased.  Solely from a common sense perspective it seems like someone who was a victim of incest throughout their childhood will probably have a different presentation than a soldier returning from war.  Whether complex PTSD is considered its own diagnosis or a subtype of PTSD, it seems useful to make that distinction in order to ensure people living with post-traumatic stress disorders are getting the best possible services.

What are your thoughts on whether PTSD and complex PTSD are distinct entities?

 

If you’re interested in reading about some of the individual research studies on the topic, the National Center for PTSD has a concise overview of the literature.

Sources:

 

Photo by Claudia Soraya on Unsplash

Book review: Be There For Me

Book cover: Be There For Me by Faith Trent

Faith Trent explains that she wrote Be There For Me: An Insight Into My Journey With Depression to “1. Show sufferers they are not alone. 2. Provide advice and guidance for those trying to support a sufferer. 3. Try to remove some stigma around depression.”  At the time of writing she was in the midst of a depressive episode and was off work, and she thought writing would be a good way to make something positive out of something horribly difficult.

The author’s depression journey captures common elements shared by many of us living with depression.  When she first became depressed, she had no idea what was happening, especially since there was no identifiable trigger or reason for her to be depressed.  She was initially reluctant to try medication, a view that she’d picked up from her mother.  There are chapters devoted to various different features of her illness, including anxiety and self-harm.  For her, self-harm was a way to somehow legitimize the way she was feeling.

She describes what it feels like to live with depressive symptoms such as fatigue, apathy, poor concentration, and the pervasive shadow of guilt.  She also explains common thought patterns in depression, including self-doubting, feeling like a burden, and drowning in shoulds.  These are not textbook definitions, but rather descriptions of the subjective experience.

She writes about the challenges of parenting young children with depression, and how the illness makes the daily parenting tasks feel like a mountain that must be climbed.  She finds it hard to be fully present with her children, and she regrets the distance from them that has created.  She also crying in front of them.  I’ve always wondered, though, if there isn’t benefit in children seeing what mental illness actually looks like, and perhaps this helps to prevent the propagation of stigma.

She identifies the essential elements she has found for managing her illness: becoming aware of her triggers and early red flags of worsening illness, maintaining work-life balance, getting enough rest, talking to a close circle of friends, exercising, and doing things that make her happy.  When her illness hits hard, she says “it cripples my whole life…  It causes me to question every part of my life, doubt my value, and make me feel like I am a burden to all I encounter.”  This struck me as such classic depressive thinking.

As is far too often the case for those of us living with mental illness, the author has experienced stigma directly.  Some people made her feel “truly inadequate and small for suffering from something that I feel they didn’t believe was real. I was patronised and made to feel like I was making it up at times.”  It was disturbing to read that a teaching colleague of hers questioned whether she should be allowed to be at work because she might pose a danger to her students.  As a nurse I have faced questions about my safety to my patients, but somehow no one realizes (or cares?) that with depression most often the real risk is to ourselves.

The main focus of the book is breaking down stigma.  She concludes that the only way to do this is for people with depression to share their stories to counter the misconceptions others may have.  I wholeheartedly agree.

 

You can find the author on her blog Shatter the Stigma.

 

You can find my other book reviews on my blog index.

Image credit: Amazon.com

Some thoughts on suicide

AFSP National Suicide prevention week 2018

Content warning: This post openly discusses suicide and suicide attempts

You can find info here on where to reach out for help if you’re in crisis.

 

It’s suicide prevention week, so it seems like an appropriate time to talk about suicide in all its ugliness.  I have attempted suicide multiple times; most were associated with my first episode of depression just over 10 years ago.  Suicidal thinking is a symptom of my illness, and one that will most likely continue to pop up when things get really dark.  It’s something abnormal that unfortunately has come to be all too familiar.

In 2007 I had three suicide attempts outside of hospital, plus multiple attempts while in hospital that resulted in me being sent to psych ICU.  At the time of the first attempt. I hadn’t been diagnosed with depression yet, but I was fairly certain that’s what was going on.  The suicidal thinking had been building, and then it got to the point where I had a plan.  The next step was getting pills, and finally I ended up taking those pills.  Each of these steps was well thought out and took some time; there was nothing impulsive about any of it.  I tried to hold off as long as I could out of a sense of responsibility to my family and other people in my life, but things were just so bleak and hopeless that the idea of remaining alive seemed totally untolerable.  The suicidal thinking was something new to me at that point in my life, so it was hard to figure out ways to cope with it.  I went through a brief phase of cutting in an attempt to find an alternate way to deal with the pain.

When I became depressed in 2010, initially suicidality wasn’t among the symptoms I was experiencing.  However, as the episode extended over the next year I began having ever-increasing thoughts of suicide.  I took myself to hospital voluntarily, but had a very negative experience and ended up being discharged without feeling any better.  I developed a suicide plan involving my psych meds.  At the time, I was working Monday to Friday with every other Friday off, and my plan was to take the pills on one of my Fridays off so no one would notice anything out of the ordinary until Monday.  Each Friday off, I would evaluate whether or not I thought I could make it through until the next Friday off.  Eventually one Friday I decided I just couldn’t take the pain anymore, and I took the pills.  Over the next few days I alternated between sleeping and wandering around delirious, and then when I didn’t show up for work on Monday they called the police.  When the police showed up at my door I was totally loopy, and they hauled me off to hospital.

I haven’t attempted suicide since then, but there have been a few occasions when I have taken steps towards enacting a plan to kill myself.  What has stopped me has been fear – not fear of dying, but fear of “failing” to kill myself.  I generally don’t tell people when I feel suicidal, partly because I don’t feel like talking will help, and partly because I have a strong aversion to going to hospital.  I’ve come to the conclusion that given the history of my illness, chances are fairly good that I will eventually, at some nebulous point in the future, end up dying by suicide.  I don’t say this because I desire this outcome or because I’m suicidal right now, but in terms of simple probability it seems the most likely.

That brings me back to what I said in my post yesterday.  To really decrease the risk of suicide in those of us living with mental illness, we need better treatment.  We need more than just an ear to listen to us; we need something tangible that will truly make a difference and create a bright light of hope.  And that can’t come soon enough.

 

Image credit: American Foundation for Suicide Prevention

How do we prevent suicide?

AFSP world suicide prevention day

You can find info here on where to reach out for help if you’re in crisis.

Today is World Suicide Prevention Day.  It’s great to raise awareness, but the problem is, people are still dying.  We can talk until we’re blue in the face about why and how people should reach out, and there are lots of great crisis lines out there doing excellent work, but why is there still a gap between that talk and the actual statistics?

The way I see it, there are two broad groups of people that it’s important to connect with when we consider suicide risk.  One is the people who are suffering in silence, and not reaching out for help because of stigma, fear, or whatever the reason may be.  I think initiatives such as World Suicide prevention Day can potentially do a lot of good in reaching this segment of the population and encouraging them to access support.

Then there are those of us who are living with a mental illness diagnosis and doing our best to access the services that are available to us, but we are still suffering.  If you’re like me, maybe the talk about suicide prevention further reminds you of the role that suicidal thinking has played and will continue to play in your life.  It’s important that we talk about it and get it out in the open, but talking isn’t enough.

To truly prevent suicide, we need better treatment for mental illness, and faster access to existing treatment.  The current treatments we have available for mood disorders are okay, but a lot of us are still experiencing symptoms, and that shouldn’t be the only outcome possible.  It can be very hard to maintain hope  when the best available treatment doesn’t take the suicidal thoughts away.  Me calling a crisis line changes nothing about my depression, so why would I even consider it?  My doctor is happy to see me more frequently when the suicidal thoughts come up, and I appreciate that, but there’s not all that much we can really do about them other than me riding them out.  Sadly, I’ve come to accept that this is part of my reality.

So if we are truly going to prevent suicide, we need a multi-pronged approach.  Yes, we need to get people talking and break down stigma.  Yes, we need to make people aware of existing crisis resources.  But we also need better treatment for mental illness, and that means more research dollars.  Because talk doesn’t do much for the many people in the same boat as I am and many of us in the mentally healthy blogging community are.

 

Image credit: American Foundation for Suicide Prevention

What’s God got to do with it?

old brick church with sign "church open today"

This post is only loosely associated with mental health, but it’s a topic I wanted to explore anyway.  I hope that this isn’t offensive to anyone, and my intent is not to criticize anyone’s belief system.

I was raised in an atheist family, and never set foot in a church as a child.  As I entered my 20’s and began travelling, I started to experience religious practice as a detached observer.  I would go into sites of worship, and observe religious services (always in non-English languages though).  I’ve been an array of churches, mosques, and temples of various sorts.  I’ve been to Jerusalem and seen the three major Abrahamic religions co-exist in an uneasy juxtaposition.  I’ve read the Quran and parts of the Old and New Testament.  And it all fascinates me.

I tend to be a left-brained, logical, scientific kind of person, and from that perspective, there just seem to be so many holes in the whole idea of religion.  There are all of these various monotheistic, polytheistic, animist, and other spiritual points of view held by people throughout the world, but for the most part it would seem they can’t all be true/right at the same time, so who’s right and who’s wrong?  If there is one God, wouldn’t he/she/it have everyone dancing to the same tune?  I understand that faith is supposed to be about belief, not logic, but I can’t help but see holes.

It also puzzles me when religions are highly prescriptive and proscriptive.  I’ll be completely facetious here for a second, but why would a spiritual belief system need to tell me that I should hop twice on the right foot, twirl around, and then do a two-footed hop?  If there is a higher power, does he/she not have more important things to do than ask me to do that little dance regularly?  And I’ll reiterate that this particular example is entirely ridiculous, but the point remains that I have a hard time accepting highly literal interpretations of holy works, particularly when they dictate individual behaviour aside from behaviours that are reflective of fundamental moral principles.

Now that I’ve gotten that out of my system, let’s talk a big about religion and mental health.  It seems very clear that religion can be a good thing.  Religious beliefs that don’t condone suicide are recognized as a protective factor against suicide.  Turning to a higher power seems like a good way to find hope and establish a framework of meaning.  I’ve certainly read bloggers who have gained a great deal of strength from their faith.  But from what I’ve read, sometimes members of faith-based organizations will offer only a very narrow form of support to those with mental illness, like the argument that meds aren’t necessary and more prayer is the only way.  I would imagine there’s a great deal of variability not only among faith traditions but among individual community-level groups, and so the problem is likely not religion per se but what some particular groups choose to do with it.

To further complicate matters, religion is sometimes incorporated into people’s mental illness.  I’ve had various clients who thought they had a direct hotline to God.  My last boyfriend, who had schizophrenia, was not normally religious, but in the context of his illness he believed that he was able to interpret the bible in a special way.  Sometimes he would spend hours writing nonsense messages he thought he was receiving from the bible.  What does become interesting, though, is trying to tease apart genuine religious beliefs from religious-themed delusions or hallucinations.  In some cases hearing the voice of God may be considered religiously or culturally appropriate, and the DSM cautions that this sort of thing needs to be taken into account in determining whether someone is having experiences consistent with a psychotic disorder.

It’s highly unlikely that I’ll be signing up for any religion anytime soon, but I will probably maintain my sort of detached fascination with all of it.  What I do hope, though, is that all faith traditions will take advantage of the power they have to promote the healing journey of people living with mental illness.  Rather than blaming mental illness on things like lack of faith or prayer, religious organizations should step up to the plate and make sure they are part of the solution rather than part of the problem.

Your thoughts?

 

Photo by Ryan Ng on Unsplash

CBT for insomnia

woman sleeping in bed

Sleep – so important to have, yet sometimes so hard to get.  Whether it’s depression where you’re exhausted but can’t sleep or mania where you have too much energy to feel the need for sleep, insomnia is something that spans across diagnoses.  For many of us, medications are an important part of getting a decent night of sleep, but there are a variety of other measures that can be tried, including cognitive behavioural therapy (CBT) specifically targeting insomnia.  CBT for insomnia focuses more on the behavioural aspect than the cognitive, and there are books and manuals developed specifically for this area of focus.  Here is an overview of some of the main elements of CBT for insomnia:

  • Sleep hygiene: most of us are familiar with recommendations like avoid caffeine/alcohol/screen time before bed, don’t nap during the day, and get regular exercise
  • Do a sleep log: while we may think we’re aware of our sleep patterns, chances are keeping a log will give a better understanding (there’s an example in the treatment manual link below)
  • Increase sleep efficiency: this is the ratio of time asleep divided by time in bed; to increase sleep efficiency, the initial goal is to spend less time in bed.  Initially this may mean less sleep, but in the longer term it will result in an improvement.
  • Increase sleep drive: napping during the day makes us less in need of sleep at night
  • Avoid negative associations with bed: with insomnia, staying in bed awake for long periods can lead to the bed being associated with being awake and frustrated.  This can be changed by only going to bed when sleepy, only using the bed for sleep/sex, getting out of bed if you haven’t fall asleep after about 15 minutes, and hiding the clock.
  • Wake up at a regular time:  this is essential in CBT for sleep, and is counterintuitive in many ways.  The idea is to get up at the same time regardless of how long or how well you slept, even if it means disrupting a sound sleep.  Bedtime is variable, but the goal is to keep the waking time consistent every day.
  • Challenge thoughts related to sleep: some common sleep-related myths, according to the University of Washington’s treatment manual:
    • I need 8 hours of sleep to survive
    • If I don’t get a good night’s sleep, then … (something bad will happen)
    • If I’m having trouble sleeping, I need to try harder
    • If I have a bad night of sleep I should try to catch up on sleep later

 

CBT-i Coach app logo

The CBT-I Coach app from the U.S. Department of Veterans Affairs has some useful tools and trackers to apply this information.

 

The info in this post is based on the CBT for insomnia treatment manual available from the University of Washington.  More information is also available on the Society of Clinical Psychology website.

 

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Treatment resistant depression: When what’s supposed to work doesn’t

resistance word graphic in the form of a knight with sword and shield

Wouldn’t it be nice if the treatment of depression was simple?  Unfortunately, there’s nothing simple about depression treatment in the real world  Treatment resistant depression (TRD) refers to illness that hasn’t respond to trials of adequate duration and dosage of at least two antidepressants.  The STAR*D research study found that only about 1/3 of people get well with one anti-depressant trial, a further 1/4 get well with a second trial, and only 67% get well after a fourth medication trail.  That’s a whole lot of people not getting well.  So if you fall into that category of TRD, what are your options?

Clarify the diagnosis

If depression isn’t responding to treatment, it’s important that the diagnosis be re-evaluated.  Could this be bipolar depression?  In that case, the treatment strategy may need to be quite different, and antidepressants alone are seldom effective for bipolar depression.  Is there a medication, medical condition (e.g. hypothyroidism), or substance use that could be contributing to the problem that needs to be addressed in order to properly treat the depression?  Is there unaddressed trauma that needs to be targeted?

Switch up the treatment

Let’s say the diagnosis is major depressive disorder and no complicating factors can be identified.  Has psychotherapy been tried?  If not, that’s always a great place to start.  Other first steps might be to increase dose, switch antidepressants, or try antidepressant combos.  Another strategy is augmentation, which refers to medications that are added onto an antidepressant regimen to achieve a greater therapeutic effect.  Options include lithium, thyroid hormone, antipsychotics, and stimulants.

Novel medications that aren’t commonly used

Ok, so what if you’ve tried, maxed out, and failed on these various treatment strategies?  Ketamine, a dissociative anaesthetic, has a novel mechanism of action, affecting the glutamate system in the brain.  It is a relatively new treatment and availability can be limited, but there is some good research supporting its effectiveness.

There are a number of other drugs that have been studied that are potential options although there isn’t a large body of research evidence to support them.  D-cycloserine is an antibiotic that at high doses acts on the same NDMA receptors that ketamine works on.  Minocycline is another antibiotic that has shows some benefit, as it calms inflammatory microglia in the brain.  I wouldn’t be all that keen to use an antibiotic for a prolonged period, particularly when there’s not much evidence to back it up.  Infliximab, which is used for autoimmune diseases, has shown some antidepressant effect in depressed people with elevated levels of inflammation.  As a biological agent, it is quite expensive.  Botox has also been shown to be helpful, and I feel like I’ve had some positive results from it.

Scopolamine, which is used for nausea, appears to have an antidepressant effect via its action on muscarinic receptors in the brain.  Studies have primarily involved 3 doses via IV infusion, with a rapid but not sustained effect.  This is something I’ve considered trying in the form of an intramuscular injection, as the oral version of scopolamine that’s available in Canada can’t cross the blood-brain barrier to enter the brain.

Blocking kappa-type opioid receptors has been associated with an antidepressant effect.  This is different from the µ-type opioid receptors which are associated with effects like analgesia and respiratory depression.  Buprenorphine, which is found in Suboxone, is a kappa antagonist but also has effects on µ receptors, and research is being done to develop drugs that are selective for kappa receptors with no activity at µ receptors.

Over-the counter supplements

There are a number of over-the-counter supplements which have shown some effectiveness in depression.  These include L-methylfolate, which may be most useful in those with elevated inflammation or impaired methylation cycles, S-adenosyl methionine (SAMe), omega-3 fatty acids, creatine, and n-acetyl cysteine, which decreases oxidative stress.  I take L-methylfolate along with vitamin B12 by injection every 2 weeks, and have noticed that if I go longer than 2 weeks my thinking and my energy start to slow down.  I also take omega-3’s, although I’m nor sure if it’s actually helping me or not.

ECT, TMS, deep brain stimulation

Other options involve the application of energy to the brain.  Probably the best known is electroconvulsive therapy (ECT).  ECT has been helpful for me in the past, but it’s difficult to manage on an outpatient basis, both because of the effects on memory and because you’re required to essentially have a babysitter on ECT days.  Another option is transcranial magnetic stimulation (TMS), which stimulates the brain through the creation of a magnetic field..  It has demonstrated good results in research studies, and because there’s no anaesthesia involved that decreases the pain-in-the-butt factor compared to ECT.  It brings about its own pain-in-the-butt factor, though, as it’s more frequent, and at least where I live it’s not covered by insurance.  Deep brain stimulation (DBS) is another option that I have very limited familiarity with.  This involves the surgical implantation of a neurostimulator device that sends electrical impulses to target areas in the brain.  DBS is also used for other conditions including Parkinson’s disease.  The potential complications sound a bit frightening, but a quick google search shows it’s the most common operation performed for Parkinson’s Disease at the major local hospital in my area.

How is your treatment working for you?  If it’s not working, what other options have you considered?

 

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Let’s get suppressing

ACT for anxiety disorders book cover

I was browsing the web for interesting therapy materials, when I came across the worksheets for Acceptance & Commitment Therapy for Anxiety Disorders on the website of one of the authors, Dr. John Forsyth.  I’ve never done ACT, but I’ve done a lot of reading about it, and it makes a lot of sense to me.

One thing that I found particularly interesting is the White Bear Suppression Inventory, which I’ve copied verbatim from the linked site; the material is copyright (1994) by Blackwell Publishing Company.  All questions are rated from 1=strongly disagree to 5=strongly agree:

1) There are things I prefer not to think about.

2) Sometimes I wonder why I have the thoughts I do.

3) I have thoughts that I cannot stop.

4) There are images that come to mind that I cannot erase.

5) My thoughts frequently return to one idea.

6) I wish I could stop thinking of certain things.

7) Sometimes my mind races so fast I wish I could stop it.

8) I always try to put problems out of mind.

9) There are thoughts that keep jumping into my head.

10) Sometimes I stay busy just to keep thoughts from intruding on my mind.

11) There are things that I try not to think about.

12) Sometimes I really wish I could stop thinking.

13) I often do things to distract myself from my thoughts.

14)  I often have thoughts that I try to avoid.

15) There are many thoughts that I have that I don’t tell anyone.

 

I was already aware that I tend to use avoidance as a fall-back strategy, but this inventory reminded me just how much I end up doing this.  I would rate myself a 5 (strongly agree) for questions 1, 2, 3, 5, 6, 8, 10, 11, and 14.  Yikes.  Yet with the current state of my treatment-resistant depression, I wonder if this suppression is the only way that I can manage to keep it together most of the time.  That sounds avoidant in and of itself, but I think it’s a legitimate question; with an illness that’s only partially responsive to treatment, are there limits to how much my conscious mind can handle?  And from a mindfulness perspective, is it useful to think about things related to past and future that I have limited control over, or is it better to just keep on chugging in the present moment? I really don’t know, and to be honest, I don’t know that I’m prepared to trust anyone enough to dig into that further.

Did this suppression inventory tell you anything new about yourself, or did it confirm anything you already knew?

 

Image credit: https://www.drjohnforsyth.com/free-resources.html

Book review: Untangled

Untangled

In Untangled: A Story of Resilience, Courage, and Triumph, Alexis Rose offers raw, forthright descriptions of the repeated abuse she experienced in childhood and into adulthood.  I would caution anyone who has experienced abuse themselves to carefully evaluate whether they are far enough along in their own healing to feel safe while reading this kind of account; I would suggest a better place to start might be Alexis’s other book, If I Could Tell You How It Feels, which focuses more on the healing process.  Aside from this caveat, this is a powerful, eye-opening book.  It is truly remarkable that Alexis has been brave enough to share her story, and is able to tell it so clearly, in a manner that is calm yet still captures the emotional devastation at the time.  She very effectively describes the hell of not only living through traumatic events, but struggling with the lasting trauma reactions afterwards.  She also touches on many questions that those unfamiliar with trauma might wonder about, including trauma bonding with an abuser, continuing to follow instructions drilled in by the abusers, and maintaining silence.

The sexual, physical, psychological, and ritualistic abuse began at an early age at the hands of her parents and others.  As she was being abused, she would imagine seeing the house next door on fire through her window; she eloquently described how this helped her to find a “golden thread of survival.  That thread kept the pieces of my shattered soul together, and gave me the strength I needed to wake up and face another day.”  Messages to remain silent were frequently drilled into her, and as she grew older, various techniques were used to keep her under tight psychological control.

Alexis describes a horrific pair of trips to the Middle East, where her mother moved after her father died.  She explained the bizarre trauma bond she developed with a man she was forced to live with who exerted complete control over her and frequently spoke down to her as if she were garbage.  She was informed that she was to serve as “a killer and a whore,” or else she herself would be killed.  She observes that by that point, “any shred of my psychological health had been obliterated.”  She ended up being tortured and beaten, and she describes the ways in which she dissociated as her mind tried to protect itself.

When she was finally allowed to return home, she began the processing of repressing the memories of what had happened to her.  Without other skills available, she relied on this strategy of repression continued for as long as she could manage. Her abusers continued to make themselves known periodically, through phone calls, mail, and in person, and she was subjected to ongoing psychological abuse from her mother.

She began to have flashbacks, although she lacked the knowledge to understand that’s what they were.  She writes that she had “no idea that the level of abuse I survived as a child was worth talking about or bothering with.”  At one point she stopped therapy because she was unable to move past the brainwashed messages that she must remain silent.  She adopted a pattern of trying to “push feelings aside and keep moving”, as this was the only way she knew to keep going.  She made the interesting distinction that “it wasn’t that I was living in the moment; I was just continually on the move.”

Things came crashing down after her daughter was hit by a car while crossing the street. Alexis writes about the extremely intense flashback triggered by the call she received from the police, and finally realized that “my mental health was hanging by a  very thin thread that was about to break”.  At that point she started seeing the psychologist who became “my healer, my teacher, and the one I would call my Sherpa, who truly started me on my journey. Walking into his office that day I began six years of a difficult and treacherous trek up the highest of mountain peaks, but that was also the day I began to claim my life and start to live, not just survive.”  She finally got to a point where she could begin “forgetting how to forget”.

Despite the horrific things that have happened to her, she has been able to leave behind those who have abused her and move forward with healing.  She has been able to draw on resilience and an ability to thrive, and has reached a place where she can be optimistic and thrive.  Alexis writes: “I’ve untangled myself. My courage has set me free, and now nothing can keep me tied to the past. I can truly live today with blinders off and eyes wide open.”  This is a truly inspiring book that tells an amazing story of survival through adversity.

 

You can find Alexis on her blog Untangled, and in an interview on the Mental Health Book Club Podcast.

 

Image credit: Amazon

 

Psychotherapy alphabet soup

multicolored letters of the alphabet floating in a pool

Some studies have shown that the quality of the therapeutic relationship between client and therapist is a stronger predictor of therapeutic outcomes than the type of therapy used.  However, it seems logical that the type of therapy should at least to some extent match up with how you tend to conceptualize the problems you’re experiencing.  Here is a brief run-down of some different psychotherapy approaches.  This is by no means an exhaustive list, and it doesn’t include things like humanistic approaches  or those therapies that do a deep dive into past issues and attachment.  GoodTherapy.org has a much more extensive list.

ACT: Acceptance and Commitment Therapy

ACT takes the perspective that resistance to thoughts and feelings is the main cause of distress.  It addresses areas such as present moment awareness, acceptance, separating the self from thoughts, and taking committed action consistent with identified values.

CBT: Cognitive Behavioural Therapy

CBT is perhaps one of the best known counselling approaches.  It considers the relationships between thoughts, feelings, and behaviours, and how each of those elements can be changed.  Evidence for and against thoughts is examined with the goal of identifying cognitive distortions that cause distress and replacing them with more realistic thoughts.  As well, new behaviours are practiced to reduce distress and promote more realistic thinking.

CPT: Cognitive Processing Therapy: This is a form of CBT for PTSD, and aims to change cognitions about the trauma that are keeping the person stuck and preventing them from fully processing the trauma.

PE: Prolonged Exposure: This is a form of CBT that aims to decrease fear and trauma responses by exposing the person in a controlled way.  This can be either in vivo (in person) or imaginal (the client is asked to vividly imagine a particular situation), or a combination of both.  It progresses based on an identified hierarchy of feared stimuli.

TF-CBT: Trauma-Focused CBT: Like CPT, this is a form of CBT for trauma, but it is geared toward children and adolescents.

CFT: Compassion-Focused Therapy

CFT is influenced by CBT, and focuses on compassion towards both others and the self.  It can be useful for people struggling with emotions like shame and self-criticism.

DBT: Dialectical Behaviour Therapy

DBT was developed by Dr. Marsha Linehan to address some of the shortcomings of CBT for treating borderline personality disorder.  The dialectic refers to the idea that the way the individual is doing things now is valid and they are doing the best they can, but they would still benefit from change.  DBT is very skill-based, with modules covering areas of mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness.

EFT: Emotionally Focused Therapy

This type of therapy consider emotions to be reflective of underlying needs, and classifies emotions as adaptive, maladaptive, reactive, and instrumental.  Therapeutic tasks are identified based on the client’s particular emotional experiences.

EFT: Emotional Freedom Technique

Not to be confused with the other EFT, this is an approach that utilizes tapping on meridian points while focusing on an issue and then an affirmation.  It draws on concepts from acupuncture and neurolinguistic programming (NLP).  There is not a robust research evidence base to support its effectiveness, although that doesn’t speak to how a particular individual might or might not respond.

EMDR: Eye Movement Desensitization and Reprocessing

EMDR is a type of trauma counselling.  The client uses horizontal eye movements to track the therapists’ fingers, and while this is being done the client focuses on an identified distressing image and the bodily sensations associated with that distress.  A Subjective Units of Distress (SUDS) scale is used to track progress, and as the SUDS score drops the therapist and client work on installing a new positive cognition.

IPT: InterPersonal Therapy

IPT is a short-term, structured approach that focuses on addressing interpersonal problems that contribute to problems with mental health, and building interpersonal communication skills.  Research has supported its effectiveness for the treatment of depression.

MBCT: Mindfulness-Based Cognitive Therapy

This type of therapy is focused on the use of mindfulness to address cognitive distress.  It covers things like acting on autopilot, being mindful of the breath, allowing and letting be, engaging in self-care, and recognizing that thoughts aren’t facts.

SFBT: Solution-Focused Brief Therapy

SFBT works on identifying and developing the skills to create changes and achieve goals.  The therapist asks particular types of questions to guide the client toward envisioning their future and identifying strengths and coping skills.

 

What types of therapy have you tried?  What was your experience like?

 

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Quora: Dumb and dumber

Quora logo

I like to answer reasonable questions about mental health on the question-and-answer forum Quora, but often reasonable questions are hard to find.  Here are some of the dumb ones I’ve come across.

 

QuestionDo you think it’s cowardice to think that people with borderline personality disorders are all evil?

Answer (the most frightening one out of several): Do you understand that the Personality Disordered person is the coward? These people refuse to take responsibility for their own actions and constantly manipulate others to exploit them for their resources, precisely because they are COWARDS. The PD’ed person uses all sorts of tools, techniques to avoid the effort it takes to exhibit and exercise conscience towards others and themselves in the home and in society.


QuestionWould long term exposure to nature be a more effective treatment for depression compared to pharmaceutical medications?


Question: How is a bipolar manipulative behavior treated?


Question: Can meditation cause schizophrenia?


QuestionDepression, anxiety, “personality disorders”, etc. can be healed naturally, so why do we tolerate a mental health system that is drug-based, and is failing people?

My favourite answer: They can be healed naturally? You are out of touch with reality.


Question: Does depression lead to materialism?

Answer: Depression … n .. materialism … no way …. It is another disease callled bipolar .. where materialism comes .. go to google for details


Question: Is depression just sad narcissism?


Question: Do bipolar people have coexisting autistic and psychotic traits?


Question:  It seems like lot of untreated people with severe schizophrenia eat out of the garbage, are unclean, and lacking sleep, but do not get sick like well people probably would. Do people with schizophrenia have stronger immune systems than most people?


QuestionPeople with no real problems to tackle usually get depressed. Is depression a disease whose first symptom is laziness?

 

Are there any particularly stupid or bizarre questions you’ve seen/heard people ask about mental illness?

My relationship with alcohol

wine glass and wine bottle lying on its side

I was raised in a household where alcohol consumption consisted of one or two beer or glass of wine the occasional evening.  I was offered small sips of both, and didn’t like the taste of either.  In my early university days, I drank, often heavily, on or two nights a week.  It was part of a package of having fun with my friends.  It wasn’t something I used as a coping strategy, I never drank alone, and I never craved alcohol on nights  we weren’t going out.  I always planned ahead to make sure I’d be safe, so as far as binge drinking goes I’d say I was fairly responsible.

As I moved a little further into my 20’s, with the odd party night as an exception, I became a social drinker, having a drink or two when out with friends doing non-alcohol-focused things.  As I moved into my 30’s and became more asocial in general, I drank alone more of the time, but the general pattern of consumption stayed the same.

But then depression got in the way.  When depressed, alcohol became an escape tool.  It would allow me to forget some of what I was feeling and thinking about.  That worked (sort of) until it started making things worse.  Because the temporary escapes meant more and more pain was getting bottled up inside, ready to explode.  That’s where alcohol, instead of lifting me off the ground, dropped me hard on my ass.

The most spectacular alcohol-triggered meltdown happened when I was 33.  Unfortunately, it happened to be at a work team-building retreat.  The team I was working on at the time was pretty laid back, and some alcohol consumption was considered normal at the annual retreats.  I had brought a 4-pack of cider, and I figured that spaced out over the course of the day, accompanied by plenty of food, that would be manageable.  Except it wasn’t.  Somehow, by the end of the afternoon, that 4 cider had got me totally drunk.  I remember standing around with a group of people and I started crying.  I went to the washroom and had a huge sob-fest.  And then I, someone who has never driven drunk ever, started insisting that I was leaving and I was going to drive myself home.  Unsurprisingly, others intervened, but it got ugly.  I was yelling at people, and they had to physically wrestle me outside and into the passenger seat of my car.  Someone drove me home in my car, and I sobbed the whole way.  Things continued to get worse from there.  A couple of months later, I ended up in hospital, and then a couple of months after that I was back in hospital again after a suicide attempt.

You would think it would have been lesson learned.  Perhaps I have, in the sense that I recognize that depression-related escapist drinking is destructive.  I still do it, but manage to put the kibosh on it before it gets out of hand.  Yet when the depression is relatively manageable, alcohol and I have an easy non-problematic relationship.

Does mental illness interfere with your relationship with alcohol or other substances?

 

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How to be supportive

hand statue supporting tree branch

Not too long ago I wrote a post on how not to be supportive of someone with depression, and had a comment from Meg that I should do a post on how to be supportive.  So here it is.  I freely admit that this is a post that’s been done many times before by many different people, so I doubt I’m coming up with anything particularly original, but here’s my two cents.

  • Validate: Validate, validate, and validate some more, and when you think you’ve validated enough, keep on validating until you’re blue in the face.  I need to hear that it’s okay to feel and experience what I’m feeling and experiencing.
  • “That really sucks“:  Don’t minimize, don’t sugarcoat.  Call a spade a spade.  Depression sucks ass.
  • “You don’t need to respond but I’ll keep messaging you unless you tell me to stop”: When I get depressed I isolate.  I hide from the world, and I think everyone most likely hates me as much as I hate myself.  If I’m feeling low, chances are I won’t respond to a message, but that doesn’t mean it’s not important for me to receive it.  If it feels like someone gets that, it means a lot.
  • Offer hugs: There is something soothing about physical contact, and it’s something I get very little of.
  • Recognize that 1:1 socializing is hard enough and anything more than that isn’t going to happen: I remember someone sprung a group lunch on me when I was prepared for just the two of us.  I was very, very unimpressed.
  • If you promise or suggest something, follow through: If you suggest we should get together next week, I don’t necessarily have any interest in doing that, but if I then don’t hear another word from you about it, I will think you hate me.  Ok maybe that’s a bit of an exaggeration, but not much.

 

What are some of the things you would like people to do when you’re not feeling well?

 

Photo by Neil Thomas on Unsplash

Trapped

truck stuck in mud

I feel trapped in several areas of my life.  Trapped in a few different ways, and really not sure how to get myself out.

The most obvious is that I feel trapped in my depression.  I’m feeling at a loss as to what to do.  I’m managing ok for the most part, but I want to be able to do more than just managing.  Yet I have a reluctance to mess with the treatment regimen that’s keeping me reasonably contained a fair bit of the time, so I’m coasting along and getting knocked off the rails whenever anything mildly distressing comes up.

I feel trapped in my career.  I’ve kvetched about this before, but there are factors outside of my control that seriously limit my options (mostly related to a former bully‘s somewhat successful attempts to destroy my career).  Plus I worry that trying and failing to push back against those external factors could further destabilize my mental health.  So I look for the path of least resistance, which is typically to stay bogged down in the status quo.

Then there’s interpersonal relationships.  I shut people out of my life.  I’ve pushed my family away, yet at the same time the maintenance of this distant but still kind of there relationship doesn’t feel very good.  Yet I have no idea how to let myself open up and move in closer, because it just doesn’t feel safe.

In a sense I feel trapped in my city.  I like where I live, and I’m very comfortable in the condo where I’ve lived for the past 13 years.  But I’m so settled in that even if moving seemed like a good thing to do for my career or other purposes, the very idea is terrifying.  The thought of having to go through the process of selling my place and trying to find a new home is completely overwhelming, to the point that I don’t even think of it as a feasible option, at least for the time being.

While some of this trapped-ness is related to external factors, a large part of it is firmly rooted in my thinking.  Yet recognizing it doesn’t necessarily make it easier to move out of my rut.  When even my rut feels scary and unsafe a lot of the time, and when past experience has clearly shown that the world often in unsafe, it’s hard to contemplate what positive change could actually look like.

 

Are there areas of your life where you feel trapped?

 

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