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.

 

 

Day 2 – 26 July 2017

07:10
Despite a rough start on day one, I did it! I went to bed at 10:30. My alarm went off at 05:30, and I didn’t want to cut someone. #smallfavors

However, I have work to do this morning. I need to create some type of schedule to accomplish all that I want in a day. Not a list of work appointments or plans – an actual effing schedule with things like – oh, I don’t know – when do I eat? I am excited about this, because I do believe that: 1) it will make following my “Treatment Plan” easier (and I’m all about easier); and 2) it will bring more intention to my days. I’m all about intention these days; more to come …

Oh, and hey, good morning! 🙂

09:22

I was in therapy and mentioned my “Treatment Plan”. Instead of the “Go you!” that I expected, my therapist gave me the internal eye-roll. (I learned from pros.)

“Whatever happened to the ‘good-enough mother’?”, she asked, referring to the work of Douglas Winnicott. I rolled my eyes back at her – not internally.

What she essentially was saying was that I don’t need to be a perfect therapist to help others heal. In practice, failing a patient can produce anger and be as therapeutic as being “perfect”. Is this Plan another ill-fated pursuit of perfectionism for me? I don’t think so … I’m going to have to think about this.

p.s. If she figured this out before me, I am seriously going to be pissed.

12:08
A noon fitness class that I am choosing to leave five minutes early to see a patient in crisis hasn’t started. I immediately feel annoyed and deprived. I HATE RUSHING.  Thank g’d for meditation classes and Headspace. I am able to loosen my grip on my annoyance and anxiety and use the extra time to stretch my hip flexors that are always tight from biking. At least the work of the class burns off most of the emotions. This afternoon feels like one in which I am eking every minute out of it. Ugh.

17:51
I’m going to hang out with a dear friend. We normally split a bottle of Pinot Noir when dining out. O could care less if I drink ETOH or not. However, I am feeling pulled. ETOH – or as I call it, “liquid Xanax” – puts the brakes on my anxiety and work stress. The minute I take a sip, I feel the liquid Xanax muzzle the anxiety, tape its wrists and stow it in the closet. For now. Not tomorrow, when my neurotransmitters ask, “Hey, where’s that ETOH?” as they busy about. FYI: your body AND your brain are both assholes. They love, love homeostasis and work very hard to undo all that we do. Nothing, nothing is without consequence. G’d, I hate being an adult some days.

I recall BrenĂ© Brown’s Ted Talk: when one chooses to use a substance, one does not get to choose what to numb. If I numb my anxiety, I numb my joy, empathy and other emotions. In addition, anxiety might be a really good thing at the end of the night when choosing to hop on the subway, walk home or take a cab. Anxiety can be life-preserving. So, do I really want to wipe all of that away? I love O. They are one of those people who make me feel so good about myself, because they truly love me. Really, really love me. And they show it. That’s friendship gold. Do I really want to numb that?!

Kind of. I know, right?! That’s the pull of ETOH for me. I am fortunate to be very smart (i.e., common sense) and bright (i.e., intelligent), but I also have great difficulties shutting off my brain. I also spend the great majority of time around equally or greater bright people, asking tough questions, pondering important matters and challenging me to be better. When do I stop? The first sip.

I prepared O and told them that I wasn’t drinking ETOH for 365 days. Of course, they responded in their typically non-plussed way. Damn, I love them.

21:00
I almost fall asleep on O’s sofa. W.T.F. Who is this person? I make a strangely adult decision, state that I need to go home and get to bed. I have a bedtime now.

21:07
I am on my way home in a cab when a message comes through from my partner. It’s a picture of one of our dogs in his lap. My heart and face smile. I love my family. I love O. I am very fortunate.

Day 1 – 25 July 2017

05:28
I had my Mardi Gras last night for the 365-day Lenten sleep hygiene. Reading therapist listserves, stoking my anxiety about the possible Affordable Care Act (ACA) repeal and playing my favorite word game in the glow of my smart phone, I watched minutes of sleep expire. I. Didn’t. Care. Ask me now about that decision. It was very fucking stupid.

08:17
I just spent 45 minutes walking the dogs and reflecting on this morning. I recalled my reading The Power of Habit by Charles Duhigg years ago and the idea of “one small change” leading to multiple changes. Earlier today – I cannot believe that I am saying this at 08:17 [sigh] – I thought, “Should I eat breakfast? When do I eat breakfast?” This small thought struck a chord deeply inside of me: I have no structure. I wake up whenever approximately eight or nine hours of sleep has been achieved or if some external factor requires it sooner (e.g., a fitness class or appointment with the orthopaedic surgeon). I eat breakfast – normally an RxBar – if I have time or on the way out the door. Sometimes I grab food – fruit, nuts or an RxBar – for time in between sessions, sometimes not. If one were to ask me basic questions about my day, such as “When do you walk the dogs in the morning?” or “When do you eat [insert meal here]?”, I honestly could not answer that question succinctly. I would say, “Well, it depends on my day! I work a lot.” Note the second sentence in that statement: it’s an excuse. Yesterday I was in therapy, and my therapist said: “So, it Netflix’s fault that you don’t go to bed on time.” I kept trying to explain my behavior to her. “So, it’s [partner’s] fault that you don’t go to bed on time.” I really was getting annoyed with her. Where was the damn empathy now?! However, less than 24 hours later, I realize that she was right. I always have a really, really good excuse. My super agile, smart brain will rationalize anything. Seriously – anything.

10:13
I am standing in the lobby of our apartment building with bags of groceries full of healthy, life-promoting food. [slight eye-roll]. No Justin’s Peanut Butter Cups are in the bags. “But it’s the organic, healthy kind of peanut butter cups”, whined my brain earlier at the market. My brain can be such an asshole. Watching the elevator alert count down, I hear the beeping of a delivery person scanning boxes in the mailroom.
He rounds the corner and states, “Hey!” It’s our neighborhood FedEx guy. Always friendly.
“Hey, how are you?”
“Doing good. Was that you sighing? You sounded so tired.”
“Yep, that was me. I got up at 5:30 today, but I didn’t go to bed on time.” [internal eye-roll]
“I got to get up at three a.m. I try to get to bed by 9 p.m., but it’s so hard.”
“Tell me about it.”

Afternoon
A formerly stable patient is at risk of hospitalization. My chest tightens due to anxiety. I make the best clinical judgment, but ultimately I have to trust in the patient that they will follow the plan. I am exhausted from a lack of sleep and want ice cream. Being tired always makes me crave sugar. [sigh] I take a walk and get some cool tea. There’s more work to do, but a member of my patient’s treatment gets back to me and contributes to the plan. I feel better that we’re all on the same page. “Everything will be okay,” I tell myself.

16:55
I am exhausted and paying for last night’s opposition toward “bed time”. I make a choice: take a ding on my treatment plan or be better present for my remaining patients. I take a 20-minute nap while also setting a boundary with myself: I have to go to bed at 22:30 without my phone in my hand.

21:06
I want to go home. I want protein. I am tired. The day’s earlier crisis, sleep deprivation and shame over not hitting my sleep hygiene goal on day one (!) have left me depleted. I want to see my family. I want to be surrounded by love and told that I’m a good person, I do good work and that everything will be okay. However, I have to chart on two patients who are high-risk. If something awful were to happen, I have to prove to a real family and an imagined judge, jury and state licensing board that I did my job, that I did everything I possibly could do to assess their safety and, if necessary, keep them safe. I reflect on my nap, and my shame decreases: I did what was in the best interest of my patients; I made the right choice. It’s then that I realize that “being tired” at work really is not acceptable. Historically, it has not impaired my judgment, but it could. I have to be on my “A game”. The shame washes on the shore of my brain like a never-ending tide. For how long have I been coming to work tired? Then I have to remind myself that I am not a therapist superhero; I am human. As I sit here tired and charting, there are sleep-deprived emergency room medical staff, nurses, pharmacists, truck drivers, and on and on. I complete the notes, leaving the remaining, no-risk documentation for tomorrow. And there it is: the slow clench between my ribs forming. Fuck.

21:32
After texting my partner with my bicycle route, I climb on my bike to ride home. Much of my treatment plan in this blog came up with my patients in the same day. I feel good about myself, knowing that I too am trying to do what they are doing. In other words, as a patient complained about their knowing that going to bed “on time” every night would help their anxiety and productivity, I not only felt the true, annoying struggle of this choice, but I also knew that I was making a real attempt to follow my recommendations. I was going to bed at the same time every night. Granted, I was on day one, but it felt good not to have that nagging, shameful feeling that I was going to spend the rest of my week going to bed based upon some whim or Netflix queue.

The streets are empty and red lights turn green as I approach, as if they too know what I need: my partner, dogs and home. I feel grateful. My legs pedal smoothly in a higher gear, translating a few months of classical Pilates. I cannot run a mile again yet, but I will. I don’t know when I will run a mile again yet, but I will. And then my chest reminds me: all is not well. If I were not a mental health professional, I would turn my handlebars and head to the nearest emergency room, thinking that my heart muscle were failing me. But it’s not. This, my friend, is anxiety. Beneath my sternum, I feel the clench, the reminder that I am not normal. My brain is not normal.

Yes, my brain is not normal. However, what could be triggering my brain now? Were it the high-risk patients? Is it a subconscious reaction to some choice that I might be facing when I arrive home? No, and no. And then, the deep knowing strikes me. The knowing that comes from a unique combination of years of psychotherapy, studying trauma and its effects on the brain, and the wisdom of experience: I suck at transitions. I hate transitions, because I fear transitions. To some who survived a trauma, transitions are the moment in the air between two trapezes – there is nothing but the strength of the previous moment to propel one through.

The immediate survival of a trauma can increase one’s need for control. Children who survive chronic trauma, such as frequent changes in caregiver, neglect, emotional, physical or sexual abuse – particularly before the age of five years – have brains who have been changed forever to respond to stressors. These children (who now can be adults) tend to have higher blood cortisol levels, leaving them in a persistent, possibly low-grade state of “flight or fight”. Earlier in my career, I worked with these children and watched over-stressed mothers trying to put little arms in coat sleeves as the child screamed in a fit of confusion and anger, not knowing what came next. “Does putting on this coat mean I leave mommy? Does putting on this coat mean I go to another, different home?” It was awful to see this wee brain reacting to history and trying to process present. (Thank g’d for the very excellent supervision and psychotherapy that got me through these years. You know who are are.)

There I am on a bicycle that I love in the air between two trapezes – work and home – and there’s not enough time to adjust. I also have to be in bed in less than an hour. Everything is going too fast, and my brain tells my body to remind me. [Chest tightens] But this I know: I’m not dying. My brain just perceives danger when there is none. I just hate, hate, hate transitions – especially ones that go too fast or that I cannot control.

I pedal faster to see my beloved partner and dogs and be in my safe home. All the while, my brain is saying, “I need more time for this.” When I walk in the door, my chest is still clenched. It will take 10 to 15 minutes for it to release.

“I’m not dying. I’m feeling better.”

 

 

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.