Day 6 – 30 July 2017

05:25
I wake up before my alarm, before our young dog. Holy sleep hygiene, Batman! I officially am one of those crazy people “who doesn’t need an alarm”. After one week. I take the young dog out and return to bed with the family – The Hub and the dogs. Despite seven hours of sleep, I am still tired. I read in bed until my fitness class.

07:47
You know that moment when you’re working really hard in a fitness class and you feel your muscles burning from effort but you really just want to punch the instructor in the face? Yes, that.

09:05
I love B, my mediation instructor. She is the most amazing person. At 20 years younger than me, I am jealous of her wisdom, her patience, her deep knowing. She is such a gift. B asks me to look for “synchronicity” this week. Aware that she likely is not referring to the album by The Police, I have to Google the term.

09:12
I find my family still in bed, and I am anxious. I made The Hub go to bed with me at 10:30 the previous evening, and he as not happy. Not one bit. I wonder if I have a mess to clean up or if he appreciates my intentions. Typical of our shared stubbornness, he reluctantly admits that he benefitted from the sleep with a qualifier. Always a qualifier. Being married to someone trained in math is a learned skill. Proceed cautiously.

10:32
We arrive home from walking the dogs and survey the contents of our kitchen cupboards scattered about from yesterday’s “flood”. If we want to eat, we have to deal with this mess, and the previous day has left us gun-shy of restaurants. I set to work, draining years-old expired food goods and washing pots and pans that were used to catch water. I know deeply that this moment would not be occurring if I a) stayed up very late and b) consumed ETOH. I am proud of myself.

13:19
I just cleaned the bathroom sink and toilet. What the fuck is happening? One week into this whole structure thing, and I have time to actually take care of and manage my life. I am both not-so-secretly pleased and secretly annoyed with myself. I work hard to not think about the hours that I have wasted in my life.

Late afternoon
I walk to the Salvation Army with a bag of donations and to the Market for meat and produce. Listening to a book on tape, The Case Against Sugar, has the opposite effect. My brain is just hearing “sugar” and then “sugar” and “sugar” again. I then think of every form of sugar that I love. I am also annoyed with the book for a variety of reasons. I cannot wait for it to end and to eat – you guessed it – sugar. My oppositionality can be such a pain in the ass sometimes. It’s like someone spent an hour telling me what to do, and I automatically think, “Oh, yeah! Try that again!”

19:12
The Hub and I have walked the dogs to the corner tavern and sit outside in the patio. I tell one of our favorite servers that I am just having a soda water. She asks the inevitable question, “Why?” I stated that I have to work later and she asks again, “Are you sure?” I think of all that I accomplished that day and say, “Yep.” It is hard in the moment, but the moment passes. The dogs soak up the sun and attention from other patrons.

20:19
I cue the Netflix to continue a series that we started the previous week and notice that I could give a shit. I am not involved and am on my smart phone. I stop myself, pause the show and stated, “I’m sorry. I can’t watch this now. The TV is yours.” I cannot watch TV sometimes; it just doesn’t garner my attention. I think that’s why I drank ETOH while watching television sometimes – to slow down my brain. The younger dog joins me in bed as I read The Ministry of Utmost Happiness. My body is weary, and I am ready for sleep to come.

 

 

Day 4 – 28 July 2017

05:31
My alarm went off. I lie in bed, feeling the weight of the week and my age. The dogs stir and look at me; I wonder if they are getting up. I consider my Treatment Plan, this blog and my accountability, and I choose to listen to my body. I reset the alarm to 06:00, wondering if this week has taught me something: I need more than seven hours of sleep a night.

07:59
After arriving at a fitness class, the instructor asked, “How are you?”

“Great! I have had a really good week,” I replied

Stop. The. Bus. This week almost has been a carbon copy of last week in terms of external stressors. Perhaps more so. Damnit. Damnit. Damnit. I feel better due to this flipping Treatment Plan. It just struck me. Fuck. I have been viewing this Treatment Plan and blog as a one-year thing and then “back to normal”. Like a diet of sorts. I really did not think doing these small things would make that big of a difference. I mean, yes, I know what clinical studies show and how I see my patients respond to these changes. However, to be “sitting in it” is much different. I feel so much better – like, really really good. Does this mean … that I … won’t ever … [insert behavior here]

[Imagines self doing Home Alone scream throughout apartment]

Nope. Nope. Nope. Not going there. Today is day four, and that’s all that I am thinking about. I have to focus on getting through the weekend: keeping my sleep schedule and not having a Pilsner are going to take some fortitude and tenacity.

“Are you with me?”, I ask my dog. Who am I kidding? She likes the patios of our City more than me. [eyeroll]

11:03
As I ripped stems off spinach leaves, I knew what I had been avoiding all week: I need a plan for tonight. It’s Friday. Historically in the summer, Friday night has meant meeting my partner and our dogs at one of the neighborhood taverns with a patio, popping open a Pilsner (or three) and sitting in the loveliness of it all. A city that I love. Sarcastic servers. Neighborhood changes. Dogs’ chilling and squinting into the sun. The name on the tavern has changed during the past seven years, but one of our dogs has been coming here on Fridays in the summer for all seven. She commands the patio by lying in the middle, eyeing servers’ trays of food. I feel as if I belong there. Like many urban dwellers, these places are extensions of my 950 s.f. home.

I could go there and order a soda water with a lime, but I know my brain: it’s an asshole. Here’s how it would go: “You’ve worked really hard this week.” “The CDC states that one serving of ETOH a day is not harmful.” “You have the calories left for the day.” And on and on. I know in my heart that I would not make a good choice today. So, I need a plan.

11:09
I call my partner at work, one of the two calls that I typically make every morning. We make plans to see “Atomic Blonde” that evening after work.

Early evening
My last patient was super anxious. Empathy has my cage rattled as well – I feel their anxiety and agitation in the room and in my body. As I turn off light switches and white noise machines, I think ahead to the evening ride to the heart of my City.

Swinging my leg over the top bar, I knew what was inevitable: a long, exhausting ride through Friday evening traffic. My saddle is too low on my bicycle. Whilst I am in the bicycle lane, ride-share drivers, double parkers and taxi cabs cause me to weave in and out of moving and standing traffic. I try to stay in the moment, enjoying music from my speaker and feeling the air move across my face. However, it’s there: the hyper-vigilance of ringing my bell, saying “heads up” and constantly looking over my shoulder and to the right for car doors. I lock up my bike, and my shoulders refuse to release the stress of the ride.

My partner and I planned to meet for a cheeseburger before the film. I arrive first, and the line is at least 30-people deep. I wonder how this could be since it is not lunchtime. “Shouldn’t this area of the City be dead by now?”, I wonder. My partner arrives and reminds me that tourists and suburban teenagers stay long after weary workers head home to their neighborhoods. Getting hangry, I watch every, single person order individually. It has now been 30 minutes, and I want to yell, “How have you not read the menu after 30 minutes in line?! Speed it up!” I am that asshole. Instead, I roll my eyes. As the line shortens, so does my patience and will. I order a chocolate shake. Not. Part. Of. The. Plan. A case of the “fuck its” has set in. I am done. I am toast. I want a g’d-damned shake and about 5,000 people inside this restaurant, outside on the sidewalk and parked in rush hour on the streets to go the fuck away so I can enjoy my evening.

Our food arrives, and we rush to eat it so that we can make it to the movie on time. We step outside onto the sidewalk, bobbing and weaving to get through crowds of tourists and suburban teenagers – some stopping dead in their tracks as they convene to decide what to do next. My legs feel leaden from the previous day’s riding and this morning’s strength training. I am exhausted, and now my stomach feels bloated and gross from the shake. My body hates dairy, and I always crash hard after eating sugar. “Every fucking thing has a consequence. I hate being an adult,” I think.

19:56
The theater lobby is quiet and cool. Everything is hidden now: people-less kiosks at which to buy tickets and paper-less smart phones that hold tickets. My partner buys his beer, and I am jealous and not jealous. I don’t want to drink ETOH, and I want my anxiety and irritability to shut down. We find our seats and settle in.

22:13
The soundtrack to the film was amazing, and I find it on my smart phone for us to listen to on the bicycle ride home. My partner and I manage to avoid right hooks, car doors and drunken pedestrians until we hit a quiet neighborhood street. They pull up beside me, and we smile. This is the best part of every late night ride. It is interrupted by my partner’s annoyance – likely exacerbated by their flight-or-fight response – at a driver’s almost right hook of me. A few blocks later, they comment on the driver again. The peace is broken. “Can we just leave the driver back there – two blocks ago?”, I ask. In the moment, I know that I am a hypocrite, that I did the same thing at the restaurant earlier: let the intrusions of the City poke at me until I was lashing out, dividing people into us/them. They know it too but say nothing.

22:23
We carry our bicycles up six steps in the lobby, and I have seven minutes to get into bed. My partner mentions something about partially reading an email, and I make a passive aggressive comment about their attention-deficit disordered thinking. It was not intended as a low blow, but it landed as such.

22:31
I crawl into bed and try to talk to my partner. They are not having it. We are both depleted. I fall asleep sad and feeling awful.

 

 

The Treatment Plan

If one came into my office with a mood disorder (regardless of additional diagnoses), I would assess the following as part of their assessment and, ultimately, diagnosis(es):

  • Their sleep patterns and sleep hygiene;
  • Their relationship with food;
  • Their relationship with substances;
  • How much they move/exercise; and
  • Their compliance with any other health professional’s recommendations.

Most people with mood disorders struggle with these areas of their lives as part of their illness or to cope with their illness. Loss or increase in appetite, hypersomnia (i.e., sleeping too much) and insomnia (e.g., inability to fall asleep or intrusive wakefulness) all are diagnostic criteria for major depressive disorder. In addition, patients who struggle with depression, anxiety or post-traumatic stress can use food or substances to cope with unwanted emotions and their resulting symptoms. As a psychotherapist, looking at how people cope can tell us much about underlying emotional disturbances. Said another way, if one is in a good space in life, they sleep well, eat for fuel and the occasional indulgence, do not abuse substances and maintain or increase their health through activity and following health provider recommendations.

So why don’t people with mood disorders do what is recommended to them to manage their health?! Because their life is one big Whack-a-Mole game of managing different, sometimes conflicting symptoms. There’s another reason: most suck at structure. (You know who you are.) If they are so depressed that they cannot get out of bed in the morning, imagine trying to go to bed “on time” that night. These patients laugh in my face when I ask about their sleep schedule. I could spend the next 500 words, providing examples on how some patients hate – even are oppositional toward – structure, but I have to stick to today’s topic: The Treatment Plan.

For the next 365 days, I am going to follow every single one of the recommendations that I make to my patients. 

My immediate response to typing that sentence: “FML”, which I imagine that I will be uttering much during the next 365 days. However, I truly want to “walk the talk” as a healthcare provider. I also want to be the best damn version of me for however many years I have left on this planet. So, here it goes.

1. Sleep hygiene
Go to bed on time (22:30) and wake up on time (05:30) six days a week. No reading backlit screens after 22:00. One 30-minute nap on one weekend day is acceptable, but not recommended.
Degree of difficulty: 10/10

2. Mindfulness
Meditate for a minimum of 15 minutes per day. Lying in bed for 15 additional minutes to “meditate” does not count. (That hurt.)
Degree of difficulty: 4/10

3. No added sugar or artificial sweeteners
To clarify, naturally occurring sugars, such as in fruit, are allowed. (More on this recommendation to my self and some of my patients to come … )
Degree of difficulty: 7/10 (A 10/10 if I am around my dear friend who is an excellent baker.)

4. No ETOH (i.e., alcohol) or other substances
Nerd alert: I have never tried or done an illegal substance or something not prescribed to me. So, I will be abstaining from the one substance that I do use: ETOH.
Degree of difficulty: 9/10

5. Close all the rings on my Apple Watch
This equates to seven 30-minute workouts per week, twelve hours of standing for at least one minute and meeting a daily caloric “move” goal (currently 800 calories). One doesn’t need an Apple Watch to measure these activity or movement goals, but it’s a consistent, workable measure for me.
Degree of difficulty: 2/10

6. Follow doctors’ orders.
If I’m prescribed a medication that I agree to, I will take it. If a physician orders a test, I will do schedule and complete it. I will not cancel my dental cleanings. (I hate going to the dentist.)

That’s it in a nutshell. It – like my stubborn head – likely is going to be very hard to crack.

Irony

I sit in a chair much of my day, deeply listening, developing hypotheses for my patients’ behaviors, staying mentally “in the room” and managing my anxiety. I am fortunate in so many ways, but one of my great fortunes is that I love my job. You know those crazy people who don’t quit their jobs after winning the Powerball? That’s me. (For the record, I did not win the Powerball.)

So, here’s the dialectical: I love my job, and it’s really hard. I’m not asking for a medal or empathy. It’s just a fact: my job is hard. Not only am I responsible for actual lives, I have a role in my patients’ lives that I take very seriously: contributing to their health, relationships and meaning. When one does this type of work, it’s really, really important to know one’s self. (This is why therapists seek therapy and consultation from more experienced therapists.) My blind spots could contribute to a death. I wake up and fall asleep knowing this truth. I love this job, and it makes me anxious. 

When I began my career as a therapist seven years after entering twice weekly therapy, my own, beloved therapist said to me, “If you can manage your anxiety in the room … it’s so important as a therapist.” I think of this insight day in and day out in my work. I cannot worry about what chores I neglected, the jury duty notice that I cannot find (!), my partner’s frustration with me, whether or not I paid the dog walker or if a healthier diet is vegan or paleo. 

However, my greatest source of anxiety in the room is this: my patient’s discovering that I’m a “fraud”. Okay, let’s slow the truck down a bit. I’m not a fraud: I have the degree, licensure and ongoing trained required to do my work. This is anxiety: I fear that one day – and I don’t know when – the people whom I love the most and my patients for whom I care will discover just how much I suck. (For the record, I don’t suck, but it’s a fear.)

This fear of fraudulence is not pervasive. Rather, it’s one of those irksome fears that decides to pop up at the most inopportune times. A diabetic patient might discuss managing their blood sugars, and the fear of fraudulence finds its voice: “Do they notice the extra weight that I’m now carrying?” A patient might share their abuse of ETOH to cope with a family visit, and I empathize; I then recall how I reached for a beer at the end of a rough day. Another patient might discuss her eating to cope with stress as I feel my own shame over using sugar to reward myself after a tough session. Add up enough of these occurrences, and I have given my fear of fraudulence a megaphone. I fucking hate it. It’s awful.

I want to be a better human, partner and therapist. I want to be a healthcare provider who “walks the talk”. I want to muzzle my fear of fraudulence by following every recommendation that I make to my patients. I’m not going to lie: these changes are going to suck hard. AND (note my use of DBT there?) the changes will pay off. I truly believe it. I believe in me. I’m ready. Or not.